From worst to first: A physician success story

How one physician bought into case management

About a year ago, Bimal Jain, MD, pulmonologist at North Shore Medical Center Union Hospital in Lynn, MA, had an average length of stay (LOS) of 10.4 days — one of the worst in the hospital.

But after a year of working closely with Aileen Day, director of medical management at North Shore Medical Center, Salem and Union hospitals, today Jain’s LOS is among the best in the hospital at 5.2 days.

Day says she tried something new when she began working with Jain. "I approached Dr. Jain with his data and the data of other doctors, but I didn’t accuse him — I just gave him the data," says Day. "His reaction was surprise. At first he thought something was wrong and he asked if I had the right information. He wasn’t mad or defensive; he was surprised. I offered to sit down with him, and we began meeting."

Day began giving Jain literature that prompted the discussion of different care options. Eventually, Jain’s record improved.

Jain says his interest was piqued when he found out his LOS was among the highest in the hospital. "I decided to take a look and see what I could do," he says.

Meanwhile, Day used the same method with other physicians and was rewarded with similar results. Her record speaks for itself: In one year, the overall LOS at North Shore has dropped by one day and readmissions have not increased. She’s helped achieve this success with the support of physicians, case managers, hospital-based managers, and delegated managers at both Salem and Union hospitals. "We no longer work independently. We work together," Day says.

The first problem Jain noticed when he began focusing his efforts on reducing LOS was an issue in his practice. Jain and his three colleagues were switching off rounds, and at any given time the physicians would be caring for five to 12 patients in one hospital. Jain says care decisions were sometimes delayed because of coverage issues.

"I started to [consider whether] patients should stay here or be moved to an extended care facility that specializes in what they need," Jain says. Another option is to send patients home and allow them to receive further services through outpatient care.

Jain says he started evaluating everything he was doing. "It forces you to find a reason for a patient to be in the hospital. When you have that awareness, it makes you provide better care and examine your patients more closely."

There is a perception that staying in the hospital longer means you will receive better care, Jain says. "From a medical standpoint, the sooner the patient goes home, the better."

Other issues previously unimportant to Jain entered the forefront of his mind, including whether the hospital offers tests on the weekend and whether test results and reports are being returned the same day. Any of these stumbling blocks, along with a host of others, increases LOS and ultimately costs the hospital money.

Jain says he can provide his services in a timely fashion, and his goal is to move his patients though the system efficiently while providing appropriate care.

Jain has resolved most of his LOS problems, but he admits it is a work in progress. His new mission is to help case managers bring other doctors on board. Physicians easily avoid dealing with LOS and case managers by either ignoring them or saying they just don’t have the time, he says. "You’ve got to approach physicians in a different way," he says. "Physicians are besieged on all sides. [A case manager’s document] is another document, and it isn’t a physician’s priority."

The key, Jain says, is understanding that doctors are competitive by nature and letting them solve their own problems. He also says case managers need to approach physicians in a nonthreatening way and try to see things from their point of view, while the case manager acts as the facilitator.

Jain offers himself as an example that such an approach can work. He admits there was a time when he would run and hide when a case manager approached him. "Now, they run and hide when they see me," he says.