As DCH Health System in Tuscaloosa, AL, began to assume more risk for patients after discharge, the leadership redesigned the case management department to meet the new challenges.

  • A masters-prepared RN assumed the role of patient navigator and follows total joint replacement patients for 90 days after discharge.
  • The case management staff narrowed down the post-acute providers with which it contracts, based on quality data and cost of care, and requires providers to submit quality data regularly.
  • The multidisciplinary staff holds rounds every day. In addition, there are long-stay rounds twice a week, and daily rounds in the ICU.

To meet the challenges of a fast-changing healthcare environment, leadership at DCH Health System in Tuscaloosa, AL, took a multipronged approach as they revised their care management model and processes to ensure patients continue to receive high-quality care and safe discharges as the industry’s focus shifts from volume to value.

The changes at the three-hospital system include creating a navigator position to follow joint replacement patients for 90 days, developing alliances with the post-acute facilities that have the best quality indicators, instituting a series of regular multidisciplinary rounds, and expanding the physician advisor role. Donna Hopkins, MS, RN, CMAC, vice president at Novia Strategies, worked with the DCH Health System staff to redesign the case management department.

“Hospitals are beginning to bear the risk for the entire episode of care, and this means we have to change the way we operate. A different role is emerging for care managers and we have to adapt,” says Carolyn Hamilton, MS, RN-BC, CDDS, CPHQ, corporate director of case management for the three-hospital system.

After DCH was chosen to participate in the CMS mandatory joint replacement program, the health system created a new navigator position and filled it with a masters-prepared RN who follows total joint replacement patients for the full 90 days after discharge.

“We are finding that these patients often need a lot of interventions to help keep them from being readmitted,” she says.

Many of the interventions have involved anticoagulant medication prescribed for joint replacement patients, she says.

For instance, one patient who received a prescription for a new anticoagulant drug couldn’t afford the steep copay, so she didn’t get the prescription filled. When the navigator found out the patient wasn’t taking the prescribed medication, she was able to give her a coupon to cover the copay.

“This woman was at high risk for deep venous thrombosis [DVT] and, without the intervention, would have been readmitted. Instead, she’s doing well at home,” Hamilton says.

In another case, the patient was told to take an aspirin a day for 30 days to prevent blood clots, but interpreted the instruction to mean that she took aspirin as needed for pain.

The navigator program for total joint replacement patients has been so successful that the health system is going to expand it, Hamilton says.

The hospital system has begun to narrow its post-acute networks by using data to zero in on the facilities with the best quality indicators and the lowest costs. They have to reduce fragmentation and costs, and that means to stop referring to facilities with the highest costs. “When we examined the data, we found that in some cases, the highest-cost nursing home was the one we referred to most frequently,” Hamilton says.

The health system requires the post-acute facilities with which it partners to submit quality metrics on a regular basis.

In the total joint replacement program, participating skilled nursing facilities have to sign an agreement that they will provide the patient with physical therapy seven days a week and to start it on the day of admission.

In addition, the hospital system also tracks data such as skilled nursing facility readmission rates and costs, and meets regularly with skilled nursing facility representatives to review Medicare Spending Per Beneficiary data and cost of care as compared to the rest of the community.

Patients at DCH still have a choice of post-acute providers, Hamilton says. “They still get a list, but the providers no longer are listed in alphabetical order. Instead, we rank them based on their Star Rating, average length of stay, and other quality data, and let the patients know that the ones on the top are those that work most closely with us and which provide the highest quality,” she says.

The case management team is working with the staff at the skilled nursing facilities on ways to prevent nursing home patients from being readmitted when they can be treated at the nursing facility.

The health system gave the skilled nursing facilities the phone numbers for the ED case managers so the facilities can contact them when they are considering transferring a patient to the ED.

When patients come back to the ED, case managers and social workers work with the skilled nursing facility staff and physicians to ensure that appropriate patients can safely be transferred back to the nursing facility instead of being readmitted to the hospital.

For instance, if the ED physician feels it is appropriate, patients with pneumonia can be returned to the skilled nursing facility for IV antibiotics instead of being admitted.

“We don’t have a problem with nursing homes sending patients to the emergency room, but keeping them when they can be treated at a lower level of care is the problem. We are working with the nursing homes so we can evaluate the patients, treat them, and send them back with a treatment plan that is carried out by the nursing home staff,” she says.

At DCH, the multidisciplinary team makes rounds every day on each medical-surgical unit. “These are transitional rounds and everybody has a role. We look at what is keeping the patient in the bed today, what are the barriers to moving each patient to the next level of care, and what we need to do to facilitate it. We encourage the team to communicate outside the formal rounds as well,” she says.

The hospital also holds long-stay rounds twice a week to discuss every patient who has been in the hospital more than seven days and collaborate on how to move them effectively and safely to the next level of care.

“The purpose of these rounds is to bring the entire clinical team together and make sure they are on the same page. Sometimes different members of the team think patients should move in a different direction, which makes it a challenge for the case management staff to move patients along,” Hamilton says.

The multidisciplinary team in the ICU has daily rounds on the ICU patients. “By collaborating, we are able to move five or six patients out of the ICU every day,” she says.

“Capacity is a real issue in our hospital. We have to constantly communicate and work together by move patients along the continuum,” Hamilton says. For example, the hospital discharged 99 patients one day in December and by the next morning, only eight beds were available.

Physician advisors provide coverage seven days a week and play an integral role in the case management process, Hamilton says. “This role has evolved beyond status reviews and supports the delivery of high-quality patient outcomes, cost-effective care, and spot-on care management,” she adds. (For details on the physician advisor program at DCH Health System, see the June 2016 issue of Hospital Case Management.)