CMs, quality managers team up for better care

Technology helps staff take proactive measures 

Merging the case management department with the quality department is "the best thing we’ve ever done," says Sharon Simmons, CRNP, MSN, CNOR, director of clinical excellence for St. Vincent’s Hospital in Birmingham, AL. Combining the departments has resulted in a tremendous improvement in quality of care as well as improved outcomes, she adds.

When the two departments at the 338-bed hospital were combined a year ago, the case managers and social workers were assigned by service line, reporting to an outcomes manager who is responsible for all quality initiatives in that area. The medical staff, process improvement staff, and peer review staff have been divided among the same service lines. "Now the case managers can spend more time with the nursing staff, the physicians, the physical therapists, pharmacists, nutritionists, and other people on the patient care team, making sure they’re all on the same page," she says.

For instance, working with physicians to improve documentation, the case managers have helped increase the hospital’s case-mix index from 1.3 to 1.54, resulting in a substantial increase in Medicare reimbursement.

When data showed the intensive care unit’s cases of ventilator-acquired pneumonia were three times the national average, the case managers instituted an intensive process-improvement project, working with the nurses to make sure the proper procedures were carried out for each ventilator patient, helping the nurses organize the questioning procedures on each patient, and educating the nurses on what they should do.

As a result, the hospital went more than six months without a single case of ventilator-acquired pneumonia. The results were so impressive that the Institute for Healthcare Improvement, based in Boston, asked the team to present its ventilator-acquired pneumonia data at the IMPACT Spring Learning Session.

Before last year, case management was a separate department that included social services. The case managers performed utilization review and were starting to work on documentation and coding with physicians. "They were operating in their vacuum, and we were in ours," Simmons says.

The quality department coordinated quality and process improvement initiatives, such as collecting data for the Joint Commission on Accreditation of Healthcare Organizations and Centers for Medicare & Medicaid Services core measures.

"The case managers are out there on the floor and are the eyes and ears of the quality people. Instead of having a few people controlling quality, we have a big department that can look at and run data and be on the front line talking to the physicians and nurses. It’s been a really good thing for the hospital," Simmons explains.

A state-of-the-art technology system is the heart of the case management and quality management initiatives because it frees up the staff to take a proactive approach, she notes.

St. Vincent’s was named one of the 100 Most Wired Hospitals in the country by Hospitals & Health Networks, the journal of the American Hospital Association.

Most of the hospital’s charts are completely on-line. The hospital is an alpha test site for a new computerized physician order-entry system.

"We hope that by the end of next year, we will have eliminated paper charts. We’re rolling it out now. The concept has been endorsed by The Leapfrog Group and other health care safety organizations as a way to prevent errors," says Simmons.

The case managers and social workers use the MIDAS+ care management system software from Affiliated Computer Services (ACS), a Dallas-based information technology firm. In addition to computers in their offices, the case managers have their own space with a computer on the unit. They also have access to computers in every patient room.

"Everything from concurrent review information for insurance or reimbursement to assessment information and discharge planning needs is all in the system. It gives us a seamless system that saves us a lot of time," she points out.

For instance, if a patient is transferred to a different floor or unit, the system automatically sends all of the patient information into the worksheet of the case manager, who will take over the patient’s care.

"It enables us to go back quickly and look for information we need without having to request the records and charts and read through a lot of documents," Simmons says. For instance, when patients are elderly, they may be confused about previous admissions or treatments. The hospital has more than 10 years of records in its archives, giving case managers instant access to all patient information.

The software gives Simmons’ department a quick way to run charts, looking at physician practice patterns, length of stay, and other outcome data.

The system allows the nurses to check off daily tasks such as holding a family conference, ordering durable medical equipment, talking to physicians about coding, interacting with the insurance company, reviewing charts, and discharge destinations of patients. At the end of the month, Simmons can pull reports showing how productive the nurses have been.

"These reports help me keep or gain my FTEs [full-time equivalents]. I can show how many people were placed in a skilled nursing facility or discharged with home health. All the case managers have to do is point and click on the screen when they enter their input," she says.

The charts allow Simmons to show the administration how many days the case managers saved in getting the patients discharged and tie the data to the decrease in length of stay.

The hospital’s quality department uses software from Philadelphia-based CareScience and creates reports using financial and outcomes data, risk-adjusting the data based on a model within the software. Among the reports are lengths of stay by physician and by diagnosis-related group (DRG).

"The risk-adjustment factor eliminates people saying that their patients are sicker than anyone else’s. We’re not just telling Dr. A that his length of stay for the same diagnosis is longer than Dr. B’s. We’re telling him, Based on risk adjustment, your patients are staying longer than they should,’" Simmons adds.

The teams meet with the physicians monthly to share data on the top DRGs and the JCAHO core measures and look at documentation issues. The software allows the team to show how many patients each physician has treated and how they are doing on the indicators. The data compare physicians to their peers, to the physicians in the CareScience database, and the national averages posted by JCAHO, she says.

"We are able to do physician profiling and create reports for the person who wields the pen and orders the patient care. That’s how we can truly get change. We’re increasing the quality of care and the safety of patients," notes Simmons, adding "when you improve quality of care, revenues go up and costs go down."

The case managers use the data to work closely with the physicians to improve documentation.

"Using the CareScience data, they show them how important it is to put patients in the proper DRG," Simmons says.

For instance, when the quality team looked at the data for pneumonia, it appeared that the hospital’s mortality for simple pneumonia was statistically significant, but when the team examined the chart, it was able to clearly show that many of the cases, with appropriate documentation, should have been coded as a higher-weighted DRG that would have reflected how sick the patient really was. "The case managers were able to show the physicians that we looked bad because we were not documenting properly," she adds.

Spotting trends early 

Because they are on the floor all day, every day, the case managers often see trends before they show up in the reports. "Now we’re able to be more proactive in live time," Simmons notes.

When the case managers are on the unit, they use their computers to communicate with the outcomes managers and ask them to look at the chart, helping catch problems that otherwise might fall through the cracks.

For instance, if following discharge after surgery, a patient is readmitted to the hospital with a diagnosis of anemia, the case manager can call attention to the quality staff and determine if something was missed in post-surgical care.

"Even if they think the patient is being treated appropriately, they can ask them to watch for certain things," Simmons explains.

Because they spend most of their day on the unit, the case managers create a close working relationship with the physicians, accompanying the physicians on rounds. "It’s not like a utilization review person from the outside is making rounds with the physician. Having the case managers on the unit makes it more of a team approach," she says.

The case manager runs the unit’s care planning team. Based on patient population, the team meets either daily or two or three times a week. The multidisciplinary team includes nursing, physician therapy, occupational therapy, pharmacy, and everyone else involved in patient care, except physicians.

"They discuss what is going on with the patient from every different aspect. They look at what is the appropriate level of care and what they can do to move the patient to the next level of care," says Simmons. Some physicians have asked to join the care planning team. In addition to analyzing sentinel events, the hospital is analyzing near misses.

When someone on the hospital staff reports an incident in which a potential adverse event was avoided, the outcomes managers put together a team of everyone who was involved and look at how the process failed and how to prevent it from happening again. "We work on preventing problems before they happen rather than analyzing them afterward. With the computerized system, we have the time to do this," she adds.

When a case manager comes into the office each morning, she logs onto the MIDAS system and gets her work list, including patients she saw the previous day and needs to see again and any new patient moved to her floor overnight.

Case managers can enter reminders into the MIDAS system about things they need to do each day, such as cases that need discharge planning, utilization review, or documentation. The system allows them to set priorities on who they should see first. For instance, patients who are not meeting insurance criteria to remain at the hospital or those who will be discharged soon are given priority.

After the case managers get their day organized in the office, they go onto the floor where they can log onto the MIDAS system and have access to patient information as they visit the rooms. "By being unit-based, they build relationships with nurses and let them know what’s going on from a quality standpoint," she says.

For instance, on the medical-surgical floor, it appeared the nursing staff were not meeting the benchmarks for educating patients on smoking cessation. The case managers determined the nurses were completing the education but not documenting. The information technology staff tweaked the computer so nurses have to document or they can’t go to the next screen.