Model lets CMs concentrate on care coordination

CMs, SWs use sequential model for patient care

By developing a case management model that frees RN case managers to do what they do best — coordinate care — Fauquier Hospital in Warrenton, VA, has reduced its average length of stay without affecting the readmission rate.

"Our RN case managers pay close attention to ensuring the patients get appropriate care. Our length of stay is below or at the Medicare average for most MS-DRGs, and our overall readmission rate is well below 20%," says Pat Gerbracht, BSN, MA, CRA, director of case management and social work at the Planetree-designated patient-centered hospital.

The hospital has three teams of case managers and social workers who are assigned by unit. One social worker supports two case managers. Case managers typically have 25 or fewer patients and review every patient in the hospital using InterQual criteria.

The social workers have a case load of 30 to 35 active cases.

"We use a sequential model for patient care. The RN case managers manage the case from admission until the patient is nearing discharge. They act as true medical case managers, constantly in contact with the physicians, maintaining intensity of service, monitoring quality measures, delays in service, or anything that wouldn't meet our standards of care," Gerbracht says.

When the patient begins to meet the discharge screen criteria, the case manager transfers the case to the social worker who puts the final touches on a personalized discharge plan.

The social workers and case managers meet every day to go over the census and touch base throughout the day. The RN case managers alert the social workers to anything that may affect the discharge plan.

In addition, the social workers conduct independent social work assessments on patients with 20-plus diagnoses that are likely to necessitate complex discharge planning, she says.

This model frees up the case managers for the degree of vigilance and interaction needed to ensure appropriate length of stays and reduce readmissions, Gerbracht says.

"The case managers are involved in managing every day of the stay, and this includes communication with the insurance companies. In practical reality, they're the only people on the team who have the information to do that part," she says.

The department has a clinical documentation specialist who serves as a resource to the case manager as well as handling documentation improvement and core measures validation.

In the past, case managers concentrated primarily on whether patients continued to meet inpatient criteria when they conducted a clinical review. Now, under the new model, they incorporate the discharge screen into their review along with severity of illness and intensity of service, says Patsy Coffman, RN, CPUR, CCM, case manager at the 97-bed hospital.

"The discharge screen shows us how patients are progressing. We could get so caught up in the intensity of service piece that we neglect the discharge screen. But that's just as important to move the patient forward. The discharge screen is the pivotal point for the case manager to get the social worker involved," Coffman adds.

When the patients begin to meet the discharge screen criteria, the social worker completes a discharge assessment and starts working with patients, family members, and the rest of the team to plan the discharge, she adds.

"Traditional thinking says that discharge planning starts on Day 1. We find that while that may be ideal, our patients and families are focused on medical concerns and not ready to talk about discharge planning at that time. Once the initial high-anxiety phase begins to wane, patients and families are ready and able to think about the next steps," Gerbracht explains.

Gerbracht credits constant surveillance from the RN case managers for the decrease in length of stay.

The key to success is getting everybody on the team involved in managing length of stay and efficient utilization of service, she adds.

"The case manager has to constantly be communicating with the rest of the team and checking in to make sure all the bases are covered and the patient is getting everything he or she needs in a timely manner," she says.

The case managers and social workers are located on the unit to which they are assigned and communicate throughout the day with the health care team, she says.

They make sure that all tests, procedures, and consults occur in a timely manner.

"As a Planetree facility, we look at stewardship of patient resources, hospital resources, and payer resources. We don't want a patient to wait over the weekend for a procedure that can be done on Saturday or on an outpatient basis," Coffman says.

The documentation specialist reviews cases for core measures and posts the Medicare length of stay on a white board where the entire team can see it.

For instance, if the patient has chronic obstructive pulmonary disease (COPD), she writes: "This person is here for COPD, DRG 191, which has an average length of stay of 4.8 days."

"It keeps the physicians aware of the time frame. Often we have physicians approach us and ask if we are within InterQual criteria. If a patient is in a gray area, we'll get the doctor to give us further background information to make the case," Coffman says.

When they assess the patients, the social worker-case management team tries to anticipate any problem that may arise after discharge, particularly for a diagnosis that is at high risk for readmission.

For instance, if patients are hospitalized with chronic obstructive pulmonary disease, the case managers go beyond the immediate post-acute period to develop a care plan for when the patient goes home.

They find out if the patients have everything they need to manage their disease. For instance, they ask patients if their nebulizer is working, if their oxygen tanks are full, if they have transportation to their next physician appointments. If not, the case manager will assist them in getting what is needed lined up.

Patients often put up roadblocks to discharge and the case managers work to overcome them, Coffman adds.

"They'll say that the clothes they came in with are dirty, and someone on the staff will take them home and wash them. We set up taxi rides to home or doctor's appointments and give patients vouchers to pay for transportation. Our purpose is to be caring but not create codependency," she says.

The hospital has set up a continuing care fund that case managers can access if patients can't afford their antibiotics or have other unfunded needs after discharge.

The hospital partners with local pharmacies and refers patients to those that offer prescriptions for $4. The case managers and social workers work with physicians to see if there is a generic version of a medication that will be less costly for the patient.

"We look at whether there is a support person in the home or if there is someone in the community who can help care for the patient. We work to develop a safety net to help the patients follow their treatment plan when they get home," she says.

For instance, if a Medicare patient with COPD or heart failure doesn't qualify for home health, the case manager refers him or her to the hospital's LIFE Center, which provides pulmonary and cardiovascular rehabilitation services. The LIFE Center includes a fitness center and offers monthly educational meetings with nutritionists, physicians, and other health care professionals.

The case manager is able to obtain a week's free pass to the LIFE Center for patients who need extra encouragement after discharge.

"We want everybody to go home with something — not just a doctor's appointment. If they don't meet home health or nursing home criteria, we try to connect them with a community service," Coffman says.

"Patients don't disappear from our radar when they walk out the door. We make post-discharge calls to patients and follow those at risk for readmission for 30 days after discharge," she adds.

The case managers analyze the data from their units to focus on high-volume DRGs that are beyond the Medicare average length of stay and those with high readmission rates, Gerbracht says.

"We are strong believers in the data-driven work approach. You have to know where the opportunities are in order to improve. Otherwise, the staff work in an unfocused, shotgun approach," she says.

The case managers break down their data to the individual physician level and have instituted a physician feedback program, reporting on the same top 10 DRGs with unusually long lengths of stay. They report back to the physicians monthly on their individual data compared to their peers.

"It's one of the best techniques we've have to modify physician practice," she says.

"Sometimes it is physician practice patterns that are the issue. Some physicians use a 'string of pearls' model and order one thing one day and another thing the next. The case managers work with the physicians to ensure that the patients have all the tests they need early in the stay so they can move to the next level of care in a timely manner," she adds.

The reorganization effort began in September 2009 and went live in January 2010.

The team of case managers and social workers first looked at the roles of everyone in the department, how they were spending their time, and identified the strengths and weaknesses in the department.

The team members created a list of all tasks from the point of admission to the point of discharge. The social workers and RNs met frequently — at the hospital, at their homes, in restaurants — and defined their own roles.

"Role definition was No. 1 on our list of concerns. We wanted to maximize the expertise of the various disciplines and let the RN case managers do what they do best and the social workers do what they do best," she says.