Innovations help medical center keep LOS low

CMs assign DRG, follow patients through stay

When patients are admitted to Alamance Regional Medical Center in Burlington, NC, care managers are responsible for assigning the DRG and length of stay and establishing medical necessity and the correct patient status.

After admission, one care manager follows the patient throughout the hospital stay and is responsible for care coordination, utilization management, and discharge planning from the beginning of the stay until after discharge.

For instance, a case manager who covers the orthopedic DRGs meets the patient while he or she is in a joint class prior to admission, then follows the patient to the medical floor after surgery. The same case manager places the patient in a rehabilitation unit or facilitates home services the patient will need after discharge.

Having one person track the patient throughout the stay has increased efficiency, assured continuity of care, and improved the discharge planning process. The efficiency helps the 238-bed regional hospital maintain an average length of stay of 4.1 days, says Beve Butler Smith, RN, MSN, CHCC, director of care management.

"Patient stays on the oncology unit can often drive the length of stay up but we have continued to move other patients safely through the continuum and keep length of stay low. Our length of stay is consistently under budget," she adds.

Assigning duties

The hospital leadership made the decision to have case managers assign DRGs 4½ years ago, and leaders integrated case management, utilization management, discharge planning, and social work at the same time.

"The idea was to increase staff satisfaction, provide equity among the case managers who are social workers and registered nurses, and increase efficiency for better patient throughput," Smith says.

At the same time, the leadership created a career ladder that includes four levels of achievement and allows care managers to be promoted based on education, experience, productivity, and performance.

"The dynamics of case management have changed tremendously in recent years. We used to deal primarily with length of stay. Now, we look at whether or not the patient's condition qualifies to be a medically necessary admission, what status they must be in, and we constantly monitor delay-of-care issues. We often have to pull a rabbit out of a hat to find a safe place for a homeless patient or medications and other services for the underinsured. Now, it is everyday work to meet the challenges that used to happen only occasionally," Smith says.

The hospital's medical records are completely electronic, which makes patient progress easily accessible on interdisciplinary screens that include clinical summaries, documentation, consultations, and discharge planning steps.

"This makes the work of the care manager much faster, as communication with all the other disciplines is now quicker and more efficient," Smith says.

DRG & InterQual training

The care managers have received extensive training on the use of InterQual criteria and the MS-DRG system and were cross-trained so they can perform those duties as well as utilization review and discharge planning. They have an average caseload of 15-16 patients.

Before the reorganization, the RNs were in charge of utilization review and social workers handled discharge planning.

"The separation of functions created poor communication within the team, and the silo effect was pronounced. The primary motive for the change is good continuity of care. Only one person accesses the medical records, spends time gathering information about the patient's insurance, monitors the care the patient is receiving, and is aware and involved in the family dynamics and discharge needs. This makes it much easier to develop patient rapport and to ensure that the patient gets the services he or she needs after discharge. Now the physician knows who to talk to about each patient," Smith says.

The patients and family members appreciate having just one care manager they can call on with questions and concerns throughout the hospital stay. Often the patient requests the same care manager if he or she is hospitalized again.

In addition to the hospital's contract with a patient satisfaction firm, the care management department conducts its own patient satisfaction survey and consistently scores 95% or better on satisfaction, she says.

"We also survey the physicians and ask how we are doing twice a year. The results are positive. One physician wrote, 'Our care managers rock!'" Smith says.

"We staff the emergency department every day from 7 a.m. to midnight, seven days a week, to stay ahead of all the regulations and keep the length of stay down," she says.

When an emergency department physician issues the order to admit a patient, the case is referred to the emergency department case manager. The care manager reviews all admissions to determine if they meet InterQual criteria for an acute care admission and to ensure that the patient is placed in the correct status. All admissions — from the cancer center, post-anesthesia care unit following same-day surgery, and direct admissions from physicians' offices — also are assessed by a care manager.

"If we are not able to satisfy medical necessity criteria, we go back to the physician and ask for more documentation. If there isn't additional information to change it and it's a Medicare patient, we issue the Medicare HINN letter, informing the patient that they could be responsible for payment," she says.

The case management department has two physician advisors that the care managers can call on during regular hours if they have questions about whether a patient meets medical necessity for an admission or for a continued stay.

The hospital also has a contract with an outside physician agency that care managers can call to review the cases any time of the day or night, seven days a week.

When there is a secondary review, the physician reviewer writes a compliance letter that is scanned into the patient's medical record.

"We use the compliance letter very successfully in denials or appeals and will have it on file as a secondary level of defense when the Recovery Audit Contractor program begins," Smith says.

When the emergency department case managers have assigned the MS-DRG, the electronic medical record automatically refers the case to the care manager who is coordinating care for that kind of patient. The primary admission review is completed by the admitting care manager and is a permanent document in the electronic medical record.

The care managers get a census report every day and begin by reviewing the newly admitted patients. They visit the patient, introduce themselves to the family, review the contact information and insurance information, and begin assessing the patient needs.

If the patient is in observation status, they give him or her a written notice of what will occur in the next 24 hours.

The assessment is documented in the electronic record and goes on to a summary screen, allowing all disciplines to see at it at a glance.

"Our goal is to make sure every patient really needs to be in the hospital and that they get the care they need when they need it so they can be discharged as soon as it is medically appropriate. Supplemental to that goal is protecting the financial resources for the hospital by adhering to state and federal regulations," she says.

The care managers work with the insurance companies, providing any clinical information they need. They continually evaluate the patient's progress and prepare for home services and medication that might be needed but is not affordable. They make daily rounds with the physicians, ensure that the patient receives tests and procedures in a timely manner, and monitor the patient's condition to ensure that it continues to meet InterQual medical necessity criteria.

Annual training sessions

The hospital holds annual training sessions for case managers with topics that include changes in coding, information on the MS-DRGs, complications and comorbidities (CCs) and major complications and comorbidities (MCCs), InterQual criteria, and other areas in which the case managers need to be informed.

"We know that insurance companies hire people with just a high school education and teach them what they need to know. Our social workers are very experienced and have a great education. We decided to include them in the education offered to registered nurses who are care managers," she says.

Initially, there were people who felt strongly that social workers could not function as care managers as effectively as registered nurses, Smith says.

"We believed that they could. That decision has worked out beautifully. Today, our social worker and RN care managers are so blended that you would not be able to tell which is which if you did not know them. The physicians are equally pleased with the services both provide. They both understand length of stay, DRG assignments, and continuity of care. They can all do all of the same things," she adds.

Express admission unit opened

The hospital recently opened an express admission unit that is used when the hospital census is high. If the emergency department physician makes the decision to admit the patient and he or she meets criteria, the patient may be placed in the express admission unit until a bed is available on the medical floor. Patients also may be placed in the unit if they are awaiting discharge to an extended care facility and the hospital needs a medical bed for patients following surgery.

"This has helped our patient flow a great deal," Smith says.

Patients in the express admission unit receive the same care they would get on the floor.

"The staff start the medication and facilitate the test the same way the staff would do it if the patient were in a permanent bed. We move the patient to a bed as soon as one is available," she says.

Each morning, the shift coordinators from each unit, the nursing supervisor, the admissions coordinator, and the care management staff meet to plan for patient flow needs and anticipate patient care issues.

"This single proactive step has decreased the stress of admission and discharge significantly," Smith says.