Combining care functions cuts managed care denials

Teamwork fosters monitoring of observation stays

Combining admitting, utilization management, and discharge planning functions in one department has fostered teamwork and increased efficiency at South Florida Baptist Hospital in Plant City, says Edward Emnett, RN, CPHQ, manager of clinical resource management.

When he shows colleagues from other facilities some of the outcomes the arrangement has prompted, "they think I'm in fantasy land," adds Emnett, who also has utilization review responsibilities at St. Joseph's Medical Center in nearby Tampa. Both hospitals are part of Baycare Health System.

A mere five observation stays since January that have exceeded the 48-hour limit and fewer than 20 pending managed care denials of payment are among the statistics Emnett attributes to the multifunctional patient care coordination department.

The key, he says, is that patient care coordinators (PCCs), nurses who perform utilization management and discharge planning, and patient care coordinator assistants (PCCAs) are part of the same team. "We have a discharge planning meeting twice a week, so if the nurses need any information about verification of benefits, or if there are any changes or corrections to the face sheet information, it can be handled right there at the table," Emnett notes.

Two social workers also are part of the department, although they actually report to a different manager, he adds.

Monday through Friday, Emnett explains, the process for direct admissions works as follows: The physician's office staff calls one of the PCCAs, who reserves a bed for the patient. When the patient arrives, he or she is greeted by a volunteer with a wheelchair, who has been told by the PCCA that, for example, "Mrs. Jones is coming from Dr. Smith's office, and we will put her in Room 65." The patient is taken directly to the room.

"No one waits for admission downstairs," he points out. Once the patient gets to the floor, the PCCA goes to the bedside to do the admission and comes back to the office to enter the data, call the insurance company, and move on with the normal admitting process, Emnett explains. "Also at that point, [the PCCA] notifies the PCC, who sees the patient as soon as possible" to begin the case management function.

If the patient arrives after 3 p.m., the PCC may wait until the following day to make the visit, except in the case of observation patients, he says. "They see observation patients very quickly, even at the end of the day." Keeping a close eye on observation stays is part of the PCCA's job, Emnett notes. "If someone is creeping past 24 hours [in the hospital under observation status], the PCCA notifies the nurse and asks if that person still needs to be here."

Prior to the aggressive monitoring that began in January, he says, "there were plenty of [observation] stays that went in excess of 48 hours, probably six to eight a month." The 147-bed hospital averages about 300 admissions a month, with between 80 and 85 observation patients, Emnett adds.

Discharge process begins sooner

The PCCs recently assumed responsibility for home health care intake, which means they can get that part of the discharge planning under way immediately, he says. "When they go in to see the patient, they're in control of enough of the process to make a difference."

If the PCCs run into an unusually complex case, they refer the patient to a social worker for discharge planning. A recent example was an unfunded methamphetamine addict who needed intravenous antibiotics. Otherwise, social workers work with emergency department patients and handle the hospital's relatively large number of young obstetrics patients, making sure they are connected with community resources upon discharge, Emnett adds.

"The boundaries are very gray, very blurry with a small hospital," he points out. "PCCs and social workers are mixed in our on-call coverage" after hours and on weekends. If a social worker is faced with a difficult funding question, Emnett notes, he or she might call a PCC for help. Conversely, the PCC might need assistance from a social worker with the counseling needs of a rape victim, as with a recent case, he adds.

South Florida Baptist is looking at gradually increasing to seven-day coverage, with plans to have someone scheduled for a few hours on weekends by the end of September, Emnett says. "Here, we don't see the need for an eight-hour day [on weekends]. If we have someone in for two to four hours, they probably can monitor the patients in observation, monitor utilization review, and pick up the [cases] that need certification information within 24 hours."

The few managed care denials that do occur, he notes, are usually the result of not having good weekend coverage.

Although the patient care coordination department seems particularly suited for a small hospital, Emnett says it could work elsewhere, as well.

"I'm absolutely convinced that we can take this model or a slightly different version and put it into a larger facility," he says. At St. Joseph's, where he still retains some responsibility for utilization review, he is experimenting with having nurses perform the same functions as their counterparts at South Florida Baptist. The decision was made recently to pull out the managed care function and have three nurses do only that.

"The next step [at St. Joseph's] with that is, 'How do we develop a team with nursing expertise and admitting expertise and pull those groups together in the same location?'" Emnett asks. "Communication between admitting and the UR area is still a problem [at the larger hospitals]."

The lack of communication - aggravated by physical separation of the departments - is behind the large number of managed care denials at Bay Care's other facilities, one of the problems South Florida Baptist is avoiding, he adds. "When the PCCAs know they need information, they go directly to the nurse - there's no 'middleman' - and they're back to the managed care company that day."

That extra step, Emnett notes, might be going to the computer or shuffling a piece of paper to get the needed information. One of the things Bay Care is considering to remedy that situation is stationing St. Joseph's utilization review nurses in the admitting department, he adds. "Before the end of the year, we will come up with something that we can apply to the larger hospitals. It won't be exactly the same, but [it will have] that link that really makes the difference."