Critical Path Network

Triad model of CM improves patient flow

UR nurses, RN CMs, social workers collaborate

In preparation for the Recovery Audit Contractors (RACs) and to improve patient flow, Durham Regional Hospital redesigned its case management department and moved to a triad model of patient care.

The case management team on each unit includes utilization review nurses who review all new admissions and continued stays up to Day 7, RN clinical care managers who are responsible for patient flow and focus on long-stay patients beginning on Day 7, and social workers who are responsible for discharge planning.

"We knew the RACs were coming and we were going to have to focus in on utilization review and assuring that documentation and patient status were correct at the time of admission. At the same time, we felt we needed staff who could spend extra time focusing on the long-stay patients and moving them through the continuum. We felt that we could speed up the discharge process if we had staff dedicated to discharge planning," says Pamella C. Aldridge, RN, MA, ACM, manager, care management, Durham (NC) Regional Hospital.

Researching other models

Before the redesign process started, the case management department team researched the model of care at different hospitals and decided that the triad model would work well for them.

Case management staff divided into groups and discussed their expectations for the redesign and what needed to be done to make it happen. They worked for about six months to develop the model.

One exercise was to divide a sheet of paper into columns for social worker, clinical care coordination, and utilization review nurse and list the functions for each job.

"We listed the expectations of each role and kept going over it to make sure that all the functions of the department were dedicated to someone on the list," she says.

Since the staff were going to work within the model, Aldridge left it up to them to make decisions about how the new process would work.

"For instance, the staff decided that the clinical care managers would pick up the patients on Day 7. I had been thinking about Day 10, but they thought it would be more effective to start earlier," she says.

The hospital was able to put the new model into place using staff who were already on board, shifting the responsibilities around for some.

"In some cases, we asked who would like to switch roles. In other instances, it depended on the needs and the experience of the staff. Some staff members were more interested in the utilization review role. We kept those who were highly experienced in the clinical care manager role," Aldridge says.

The teams are mostly unit-based and, in most cases, also are service line-based.

The clinical care coordinators are responsible for patients on one unit. The utilization review nurses generally cover two units.

UR nurses act as CMs in smaller units

In units with a smaller census and a shorter length of stay, the utilization review nurse also acts as the clinical care manager. For example, most of the general surgery patients are now outpatients, and the census on that unit is steadily declining.

The triad arrangement is in effect on the larger units, such as the medical units, where patients may have longer stays.

"The staff on each unit work together as a team," Aldridge says.

The utilization review nurses conduct the initial review to determine if a patient meets InterQual criteria.

"The utilization review nurses are the first line of defense and the go-to people if anyone has a question about criteria. If they have a question about whether a patient meets criteria, they call the clinical care manager and collaborate to make sure we get the patient status correct up front," Aldridge says.

The utilization review nurses complete an assessment to determine if the patient is likely to be at high risk for discharge needs.

For instance, a patient may be from out of state and will need post-acute services in his hometown or may be elderly and living alone and will need home health or other assistance.

If the initial review indicates that a patient is likely to have intensive discharge planning needs, the utilization review nurse immediately communicates with the discharge planner and the clinical care coordinator so they can take a proactive approach to meeting the patient's discharge needs.

"They gather as much information as possible at admission so the rest of the team will know what they need to plan the stay and the discharge," Aldridge says.

The utilization review nurses review the patient again on Day 3 for a continued stay review and continue reviewing the charts through Day 6.

If a patient has been admitted for the second time in two months, the utilization review nurse immediately contacts the clinical care coordinator, who starts drilling down to determine the reason the patient is being readmitted.

"We try to determine if we missed something in our initial discharge plan or if there was another reason for the readmission, and take action to correct the problem," Aldridge says.

The clinical care managers focus on the long-stay patients and what is keeping them in the hospital.

"They are responsible for knowing about all the patients, but they don't do the daily reviews until the patients have been there seven days. It has helped our patient flow to have the clinical care managers focus on the long-stay patients and getting them moved safely to the next level of care, rather than having to scramble to assess all new admissions within 24 hours," Aldridge says.

The clinical care coordinators review the charts of the long-stay patients every morning and talk with the medical staff and nurses to find out what has been happening with the patient.

They make rounds on the patients, review the orders, and make sure that everything that is ordered has been scheduled. For instance, if a doctor has ordered a CT scan and it has not been scheduled, the clinical care manager calls radiology and lets them know the discharge is pending so they will move up the scan.

They work with the discharge planners on facilitating discharge for long-stay patients.

Before the new model was launched, the utilization review nurses and the clinical care managers went through InterQual end-user training.

The clinical care managers are responsible for quality measures and work with the utilization review staff to ensure that documentation is complete and correct.

"The staff dedicated a lot of time to designing the model, and by the time we launched it, we felt we were more than ready to go. We are still meeting to work out any kinks and to decide what needs to be changed to make the process better," Aldridge says.

[For more information, contact: Pamella C. Aldridge, RN, MA, ACM, manager, care management, Durham (NC) Regional Hospital, e-mail: aldri006@mc.duke.edu.]