EXECUTIVE SUMMARY
Dartmouth-Hitchcock Medical Center in Lebanon, NH, reviews patients at every point of access to get their status right up front.
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Case managers cover the emergency department, utilization review nurses review surgical patients, and physician advisors are on call to the transfer center.
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Observation patients are placed in a clinical decision unit next to the emergency department; surgical patients who need a longer-than-normal recovery period are monitored in a short-stay unit.
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The electronic medical record allows clinicians to see what the other disciplines are doing in real time.
Dartmouth-Hitchcock Medical Center in Lebanon, NH, reviews every patient at every point of access to make sure that they are placed in the correct status.
“Having a strong utilization review process at the portals of entry is key for any organization,” says Amy M. Smith, RN, MSN, CCM, director of case management at the 421-bed academic medical center and Level I trauma center. The hospital is 92% occupied on average.
“We believe that having the right patient in the right place at the right time, from the front door, decreases work on the back end,” Smith adds.
The case management department uses a triad model that includes utilization management nurses, case managers, and social workers. The licensed staff is supported by a resource specialist who manages referrals, sends clinical information to payers, distributed the Important Message from Medicare letters, and performs other clerical tasks.
The department divides the responsibilities to cover all points of entry where patients are admitted by doing the following:
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RN case managers staff the emergency department 12 hours a day, seven days a week, and work with the physicians to identify patients who meet admission criteria or who will require observation services and plan a safe discharge for patients who can be treated and released.
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The hospital’s team of eight physician advisors rotate being on call as medical director for the transfer center and assist in determining the status of patients being transferred from other hospitals and direct admissions from physician offices. They cover the transfer center 24 hours a day. “The physician advisors act as a gatekeeper and ensure that the status is correct for incoming patients,” Smith says
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The utilization management nurses review the operating room schedule every morning and make sure that each patient has an appropriate order. The utilization management nurses also review patient charts after surgery to identify any patients who may meet inpatient criteria.
The hospital has a five-bed clinical decision unit adjacent to the emergency department for patients who are receiving observation services. Among the diagnoses or complaints of patients placed in the clinical decision unit are chest pain, transient ischemic attack, strokes, syncope or near syncope, minor intracranial hemorrhage, asthma, chronic obstructive pulmonary disease, dehydration, cellulitis, and heart failure.
Surgical patients who do not need an inpatient stay but cannot be safely discharged are transferred from the recovery room to the 12-bed short-stay unit when the normal recovery period has passed.
When the hospital’s capacity is high and all the beds in the clinical decision unit are filled, the hospital places observation patients on the inpatient units. “This isn’t ideal but the utilization review nurses review the charts frequently to ensure that we are actively managing the patients and that they are not staying in observation longer than necessary,” Smith says.
The hospital has documentation specialists who review the medical record to ensure that the documentation is detailed and complete and works with the physician advisor to give real-time feedback to the physicians, she says.
At Dartmouth-Hitchcock, the records of Medicare patients are triaged to be reviewed first over those of patients with commercial insurance, Smith says. The utilization management nurses review observation cases daily, starting with the day of admission, and work closely with the RN case managers to make sure that patients are getting the services and tests they need in order for the physician to determine if patients can be converted to inpatient or be discharged to home.
A key to managing observation patients has been an electronic medical record system that allows all members of the treatment team to see what other team members are doing in real time, she says. The hospital added a case management module to the electronic medical record system last fall.
“Before we started using the new case management software, several different systems were being used in the hospital, making communication difficult. Now, the utilization management nurses can easily identify the observation patients when they log into the software system. It helps them set their priorities for the day,” Smith says.
Each unit has multidisciplinary rounds each day, during which the team reviews the record of each patient, his or her status, and what needs to happen that day to move the patient toward discharge. In the case of observation patients, the team makes sure that whatever orders are needed for test or procedures are issued in a timely manner. The rounds are attended by the case manager and the charge nurse on the unit, along with a representative from the physician team, usually a resident.
Case managers document on the computer during rounds and during patient encounters. The utilization management nurses document their reviews. “Even though the utilization management team is in the office and the case managers are on the floor, they see the same thing on the screen and each knows what the other is doing in real time,” Smith says.
The utilization management nurses give priority to observation in an attempt to catch patients who are being discharged and meet the criteria for Condition Code 44 so their status can be changed while they are still in the hospital.
“We review patients rigorously to determine if we should change the status using Condition Code 44. The utilization management nurses notify the patients during the day. After hours, it’s the responsibility of the emergency department case manager. We also conduct self-denial reviews after patients are discharged to make sure we didn’t miss anything,” she says.
Smith’s goal is for members of her staff to become experts on the various rules and regulations that affect the hospital and case management. For instance, she occasionally assigns one case manager to shift his or her workload to another case manager and spend the work day studying new Medicare regulations, then report back to the team.
“Things are changing so fast that it’s impossible for everyone to know it all,” she says.
