Critical Path Network

CM redesign proactive approach to reform

Hospital pairs RN CMs with physicians

In 2004, as talk of health care reform escalated, North Oaks Health System appointed a multidisciplinary process improvement team to determine what changes the hospital needed to make to prepare for where health care was going in the future.

"We were beginning to hear a lot about health care reform, and we wanted to be ready. We knew that we needed an improved alliance between our hospital and physicians and improved education with patients and our community about what an acute care hospital does," says Sherri Hayes, RN, CCM, assistant vice president of case management at the Hammond, LA hospital.

"For many years, and even today, people have the impression that you get sick and come to the hospital, then stay until you are completely well before you return home. We knew we had to change the mindset in our community and that it would require more interventions than the bedside nurse has time to deliver," Hayes says.

When the team analyzed the hospital's data, it found a higher-than-average length of stay compared with similar hospitals. An analysis of the hospital's Program for Evaluating Payment Patterns Electronic Report (PEPPER) data showed that there also were issues with one-day stays and higher-than average readmission rates.

"When we analyzed the length-of-stay and readmission data to determine opportunities for improvement, we kept coming back to the need for improved communication," Hayes says.

At the time, the nurse case managers and social workers were assigned by unit in the classic utilization review/discharge planning model, Hayes says.

"The nurses were in the charts all day, rather than seeing patients, and spent a lot of time on paperwork and trying to communicate with payers. The social workers screened the patients and intervened with those identified as high risk. They implemented any orders that were related to discharge planning," Hayes says.

Although the hospital is moving toward implementing a hospitalist program, at present, the admitting physicians all are in community practice.

The hospital's admitting physicians typically have patients on multiple units and were getting calls from multiple care managers throughout the day.

The team decided to assign the care managers by physician in order to build relationships, decrease the number of calls the physicians were getting from multiple parties, and to build a strong working relationship between care managers and physicians.

"We decided to give each physician a point person who works with them. As the care manager becomes more important to the physician, the issues facing the care manager take on increased importance with the physician," she says.

The department kicked off a pilot project in April 2004 that paired a case manager with an internal medicine physician who was the biggest admitter at the time.

The department was on the brink of expanding the program to include four more primary care physicians when Hurricane Katrina roared through the Gulf Coast, creating a health care crisis for the hospital and the entire region.

The hospital's location in Hammond, about 45 miles northwest of New Orleans, made it a primary destination for people being evacuated from New Orleans and the Gulf Coast.

"This is a fairly rural community that serves as a bedroom community for the larger cities of New Orleans and Baton Rouge, which is about 35 miles to the west. After Katrina hit, our community experienced an influx of 30,000 people. It overwhelmed the hospital, and especially the emergency department," she says.

At the time, the hospital had a social worker in the emergency department during the day, with the emergency department nurse serving as the gatekeeper in the evenings.

A care manager was on call and screened patients over the phone with the emergency department charge nurse and made recommendations on the appropriate level of care.

To make things worse, the hurricane wiped out 75% of the psychiatric beds in the Greater New Orleans area, and the suicide rate increased an estimated 300% in the first four months following Katrina.

"We were placing patients who came into the emergency department in facilities as much as 300 miles away because there were no available beds in this region. We had to have social workers in the emergency department 24-7 to handle placement of the psychiatric patients," she says.

To deal with the huge influx of patients in the emergency department, the hospital expanded the program, putting care managers and social workers in the emergency department 24 hours a day, seven days a week.

"The emergency department is the front door to the hospital. About 70% of our inpatients come through the 20-bed emergency department, and we see over 70,000 patients a year. We knew we had to improve throughput and get patients out of those beds and into another level of care as rapidly as possible to make room for the next emergency," she says.

During the crisis that followed Hurricane Katrina, the hospital put the project to assign case managers by physicians on hold.

By February 2006, Hayes knew that implementation of the new model couldn't wait.

"We found that we couldn't do without the care manager-physician alignment. Instead of gradually rolling it out with just a few primary care providers, we ended up going full force. It's been extremely effective," she says.