Critical Path Network

CM protocol results in decreased denials

Physicians delegate patient status determination to CMs

Payer denials for inappropriate observation patient status dropped by 50% the first year after Good Samaritan Hospital in Dayton, OH, instituted a case management protocol that delegates responsibility for determining patient status to case managers.

The protocol was developed by the multidisciplinary integrated care management status team, which worked closely with Ohio KePro, the hospital's quality improvement organization, and was approved by the hospital's medical executive committee.

The hospital is licensed for 577 beds and has an occupancy rate of about 73%. The case managers are unit-based and have an average caseload of up to 25 patients a day.

The hospital piloted the protocol in the ED, where the majority of patients are admitted, beginning in May 2007, and rolled it out throughout the hospital a year later, says Teresa I. Gonzalvo, RN, MPA, CPHQ, LNC, director of integrated care management.

"About 70% of admissions come through the emergency department, and therefore, that department has the most status assignments. We decided to roll the process out in the rest of the hospital after we piloted it in the emergency department because of the size and number of services. We had many access points and many dissimilar processes and had to come up with a way to make it work," Gonzalvo says.

At Good Samaritan, all admitted patients are reviewed by a case manager for admission status, regardless of their access point or payer, she reports.

The case managers use InterQual criteria and Medicare guidelines for medical necessity as the basis for determining whether the patient will be in observation or inpatient status. CMs are responsible for assuring the correct status from admission through discharge.

The admission status of patients admitted through the ED is determined by case managers who cover the department 24 hours a day, seven days a week.

When patients who come to the hospital at other access points get to the floor, their admission status is determined by the case managers on the floor who work from 8 a.m. to 4:30 p.m., Monday through Friday. After hours and on nights, weekends, and holidays, the ED case managers review the admissions of patients admitted at all access points and ensure that their status is correct, Gonzalvo says.

Before the protocol was implemented, two case managers covered the ED for 12 hours a day, Monday through Friday.

Adding FTEs to ED

The hospital committed an additional 4.3 FTEs to provide case management support in the ED around the clock.

Since the protocol was implemented, there has been a significant increase in the ratio of patients admitted to inpatient status, rather than being in observation, says Donald P. Sickler, MD, medical director, integrated care management.

Having 24-7 coverage in the ED was essential to the success of the protocol, Gonzalvo adds.

"When we didn't have staffing on certain nights, the case managers would have to review admissions from the previous night along with surgical admissions and were always behind in their work," she says.

The hospital's ED bed request form includes a section for the case manager to assign the patient to observation or inpatient status and sign and date it. The form is not part of the permanent record.

Case managers also fill out a case management status sheet, which includes the date and time the patient is placed in inpatient or observation status and check-off boxes for the rationale for the status assignment. The sheet is signed by the case manager and placed in the medical record. If the status changes, the case manager fills out a second sheet and puts it in the record.

If the attending or admitting physician disagrees with the status determination, the case manager discusses the disagreement with the admitting physician and, if there is no resolution, refers the case to the medical director or the vice president of medical affairs. If there still is disagreement, the final determination is made by two physician members of the hospital's utilization review committee as specified by Centers for Medicare & Medicaid Services guidelines.

As physician advisor to integrated care management, Sickler makes daily rounds with the case manager on each unit, including the ED. He discusses cases with them and mediates when there is a disagreement with the medical staff. He is available by pager throughout the day.

If the ED case managers have questions about a difficult case when Sickler is not available, they call the integrated case management manager or director and, if it's still a gray area, assign a default observation status to the care. The situation is discussed with Sickler or the vice president of medical affairs as soon as possible.

On weekends, nights, and holidays, the emergency department case manager runs a report of observation cases, and then reviews the charts of the new admissions, and ensures that the patient is assigned the right status.

"The case managers can assign the correct status or have a conversation with the admitting physician to determine what the disposition should be, based on medical necessity," says John W. Clark, BN, BSN, manager, case management.

Having someone review patient status on weekends is critical to ensure that those patients in observation who now meet inpatient criteria are placed in the appropriate status, Gonzalvo says.

"A patient admitted on the weekend may initially be appropriate for observation but may need to be converted to inpatient status. If someone doesn't make sure the status remains appropriate, we end up with two days of observation for someone who should have been an inpatient," Gonzalvo says.

The team created a user-friendly manual for Medicare's inpatient-only list to ensure that patients who receive surgical procedures on the list are admitted to the hospital as inpatients.

Surgery schedules also use the manual to determine if patients should be admitted as inpatients. The case managers re-evaluate patient status while patients are in the recovery room.

Unit-based CMs manage post-surgery patients

The unit-based case managers take turns rotating through the post-anesthesia care unit to determine admission status for patients who are in recovery following surgery. If the unit that's assigned recovery room responsibility has a big caseload on its regular unit that particular day, another unit takes over the process.

"It's easier to get these patients admitted in the right status if someone goes to the recovery area, rather than trying to manage the admission status when the patients get to the floor," Clark says.

In isolated cases, when a case manager doesn't see a patient within 16 hours of admission, the patient status defaults to observation. Then the case manager can review the chart and continue the status as observation or assign the status as inpatient if appropriate.

"This gives us up to 16 hours after admission to make the initial status determination. Since we have case managers in the emergency department 24-7, a default status happens very rarely, if at all," Gonzalvo says.

The case manager can convert the defaulted observation status to inpatient by the case management protocol at the time the need for acute inpatient level of care is determined, she adds.

One challenge is patients who must have a three-night stay to qualify for Medicare coverage of post-acute facilities.

"We want to avoid having patients who need to go to a nursing home but don't have a qualifying three-day stay because of a default to observation status," Clark adds.

Almost immediately, the hospital experienced an increase in teamwork and communication among staff, along with a huge positive response from the medical and nursing staff, Clark says.

"We saw an increase in consistency in applying criteria and in using the inpatient only list, which we attribute to additional training. The integrated case management department gained increased visibility in the hospital by discussing the project with the various departments," he says.

(For more information, contact Teresa I. Gonzalvo, RN, MPA, CPHQ, LNC, director of integrated care management, Good Samaritan Hospital, e-mail: