Memorial Hermann takes home Franklin

CM in and out of the hospital shines

It was nice to win a national award for case management last winter, says Pat Metzger, RN, MSA, system executive for care management at Memorial Hermann in Houston. But that wasn't the aim when the program started a decade before the Franklin Award landed on her desk. Then, the system figured the only way to survive the coming healthcare environment was to redesign case management. Some of what they did, particularly in terms of observation units and improved community health, explains why they won the award, and it has lessons for the QI community.

They started from the ground up, asking what did they want case management to do and how did they want it to change the way they delivered healthcare. Using a system approach, they revamped every policy and procedure and made sure that what was used in one hospital, in one unit, in one room, was the same in every other setting in the system. "That gives us a common platform against which we can measure our performance," she says.

They look at several indicators — length of stay, cost per case, avoidable days, number of hours in observation, patient satisfaction scores, and avoidable ICU days. They look at administrative data like response times from third-party payers and how able they are to move patients from one level of care to the next outside the organization.

One major issue they dealt with in the decade-long change was with observation services. "We brought in key leaders from across the system — nursing, physicians, executives — everyone," she recalls. "We looked at what observation is, CMS requirements for it, where we meet them and where we don't. We then did Six Sigma break-out groups and looked at workflow processes and procedures to change the way obs services worked for us."

CMS regulations changed so that observation services start times changed. "If patients are receiving other monitored services, you have to back out those times from the hours observed. So if someone is going to the cath lab from obs, you had to back out those minutes in the cath lab." First, they calculated the average time for a cardiac catheter procedure. "We automatically deduct that from the total observation time. We are moving to a time where we can time stamp when they get there and when they leave, but for now, that's how we work it."

Every hospital in the system has to track metrics like the number of hours in observation services, the number who were in for less than a day, those in 24-36 hours, and those who were in over 36 hours. "The goal was to decrease our total hours, and we saw a lot were staying longer than 24 hours," Metzger says. "Medicare will pay for up to 48, but only if you are waiting for results of tests and procedures done in the first 24. We wanted to make sure we were not ordering new tests at hour 25 that weren't related to original cause."

Another QI element that came out of the summit related to documentation. There are specific documentation requirements related to physician intervention, frequency of intervention, and tools that remind the nurse or doctor to jog his or her memory that this patient needs to be speeded along. Memorial Hermann created an electronic check sheet that automatically hits the nurse with a task list every two hours.

Doctors also needed prompts to promote behavior change. Physicians came on board and developed 32 common observation services pathways that get implemented when the patient is entering the unit. "There are prompts for docs to check on status, or to order tests," she explains.

Aside from the observation unit work, Metzger implemented a Medicare summit where she asked questions about Medicare rules of participants. "That helped us determine what areas of Medicare knowledge we needed to work on." For instance there was a question about blood administration. "People didn't understand that whether in- or out-patient, the first three units of blood are the patient's expense. After that, they have to pay 20% copay. We did this with our senior executives, nursing leaders, case managers, and physicians."

When a case manager had to talk with a physician before about why they were doing something, physicians often balked, wondering who the case manager was to question the doctor.

But they often had to go back to patients and explain that they were going to have a bunch of expenses they weren't anticipating. The Medicare quiz put case managers and physicians on the same page.

Memorial Hermann still uses the quiz in case management classes for staff. "I think our knowledge about Medicare has improved from it."

The award also noted the improvements in limiting readmissions. Houston has the highest population of uninsured patients in the country. They developed the COPE program — Community Outreach for Personal Empowerment — which helps frequent fliers in the ED manage their health and get connected to community resources. "That's saved us about $4 million since we started," Metzger says. They also started a chronic disease management program for CHF and diabetes patients that has saved another $9 million. They use telephonic case management — daily, weekly or monthly depending on the risk stratification of the patient. They will be expanding that to COPD patients soon.

Case management may have been a path to an award for Memorial Hermann, but Metzger says you need to jump on this bandwagon now. With all the new CMS regulations and payment changes, hospitals need to realize they "own patients for 30 days after discharge. We need to choose our post-acute partners strategically and partner only with those people who understand that we don't want patients bouncing back but still getting exactly the care they need when they need it."

Putting a team and program in place that takes the patient into account from the moment they come in, always with an eye on appropriate discharge, is the way of the future. "We are laying the groundwork," she says. "We are finding that those providers are excited about the potential to do this and potentially really improve healthcare for patients."

For more information on this topic contact Pat Metzger, RN, MSA, FAACM, FAABC, system executive for care management, Memorial Hermann Hospital, Houston, TX. Email: