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But you must consider managed care goals first
By Patrice Spath, ART
Brown-Spath & Associates
Forest Grove, OR
Stanford (CA) University Medical Center reportedly spent $21,350 to develop a knee replacement surgery pathway.1 Case management specialists suggest one case manager is needed for every surgical patient, whereas one case manager is needed for every 15 to 18 medical patients.2 It is obvious that reducing the costs of hospital care is going to take some up-front expenditures!
While large facilities may have sufficient discretionary income to absorb these costs, what about smaller hospitals with very tight budgets? In addition, larger facilities are more likely to get a return on their pathway or case management investment just because of sheer numbers. Stanford reported an approximate savings of $3,000 per case after the knee replacement pathway was implemented. For Stanford, that savings quickly offset the cost of pathway development because of their large number of admissions for knee replacement surgery.
What about the small hospital at which far fewer surgical procedures are performed each year? The financial gain may be slow in coming.
Hospitals with fewer than 100 beds may find it challenging to get a return on clinical paths or case management program investments. With the low numbers of patients in each diagnostic/procedural category, the hospital’s ability to obtain a significant financial and quality return on investment is questionable. That is why it so important to consider the hospital’s managed care goals before embarking on development of any program designed to improve care coordination. Admini stra tive and medical staff leadership at small hospitals must carefully consider what they hope to achieve from a resource management and performance improvement perspective. The goals should be expressed in measurable terms. (For examples of goals a small hospital might seek to achieve from care management activities, see box, p. 46.).
To achieve these goals, the small hospital has several different action plan choices: improve preadmission planning; more closely monitor appropriateness of admissions and continued stays; expand discharge planning; implement case management; institute stop orders for high-cost tests/treatments; design preprinted physicians’ orders or protocols; expand community health services; expand community-based case management; give physicians round-the-clock access to discharge planning/social services support; design and implement clinical paths with input from physicians and other clinicians involved in patient care; and so on.
Small hospitals should explore all of their resource management options and select the least costly initiatives that are most likely to achieve goals. For example, if the goal is to "Decrease overall cost of care for congestive heart failure patients by 10%," first determine where costs are highest. The hospital may find that the most effective way to reduce costs is to have the nurse manager of the critical care unit conduct daily rounds to encourage triage of patients to a step-down unit as soon as they are clinically stable. Another goal might be: "Improve the clinical care provided to patients with congestive failure." This goal is best achieved through development of "point-of-care" reminder tools (e.g., clinical pathways, preprinted standing physician orders, treatment protocols).
Most important, involvement and commitment is needed from physicians, managers, and staff who "own" the clinical processes involved. The owners of the process must have ownership of the choice of tactics, the implementation, and eventual analyses of the results.
• Start with data.
Administrative and medical staff leaders, as well as all clinical caregivers, should understand where the hospital is failing to meet its managed care objectives and why meeting these goals is important. Use data to substantiate the value of whatever initiative may have been proposed. Caregivers must appreciate the benefits of paths, case management, or any care coordination tactic. If new patient management initiatives are viewed by caregivers as "make work" additions, clinicians’ endorsements will be difficult to secure.
• Explore universal paths.
Because of the low number of patients in any one diagnosis or procedure category, small hospitals may wish to explore the development of "generic" paths. These paths are applicable to a larger group of patients because they are not specific to one diagnosis-related group. The path in the accompanying pathway (see p. 47) covers the care provided to all patients in the ambulatory care unit who receive general anesthesia. While each patient may have slightly differing care needs, there may be enough similarities to allow development of a universal path such as this. Slight variations of this path can be designed for patients having local, epidural, or block anesthesia. Universal paths also can be developed for inpatients whose care patterns are similar.
• Involve all providers.
Small hospitals must work closely with pre- and post-hospital providers to develop care coordination initiatives that cover an entire episode of care. For surgical patients, involve physicians’ clinic nurses to determine patients’ preoperative care requirements. When designing pathways or initiating case management for high-risk patients, be sure to collaborate with home care agencies, nursing facilities, public health nurses, community mental health agencies, and other out-of-hospital caregivers. Not only will the hospital get a better return on its care coordination investment, but patient and community satisfaction also will be enhanced by reducing fragmented care.
• Concentrate on a few high-risk patient groups.
When developing condition-specific pathways or choosing patients for case management interventions, start with patient populations that include more than 150 admissions per year. Target populations do not need to be diagnosis-specific. For example, case management services may be initiated for patients meeting the following criteria:
— requires assistance with activities of daily living;
— is a caregiver for someone else;
— has had three or more hospitalizations last year;
— is admitted from another facility (hospital or skilled facility);
— is receiving home care services;
— has a serious memory loss;
— has a history of repeated falls in the past year.
Many small hospitals are finding that five clinical pathways for high-volume diagnoses, a few generic paths, and case management for select high-risk patients meeting criteria such as those listed above are sufficient to achieve their resource management goals.
With careful planning, small hospitals can ensure a return on their resource management investment. Many small hospitals throughout the United States have successfully integrated paths, case management, and select utilization management interventions into their overall patient care strategy. If you want to succeed, don’t use the cookie-cutter approach. Carefully select affordable interventions that are most likely to be accepted by caregivers and achieve your resource management goals.
1. Macario A, Horne M, Goodman S, et al. The effect of a perioperative clinical pathway for knee replacement surgery on hospital costs. Anesth Analg 1998; 86:978-84.
2. Newell M. Using Nursing Case Management to Improve Health Outcomes. Gaithersburg, MD: Aspen Publications; 1996, p. 33.
1. Reduce length of stay in high-volume surgical DRGs for Medicare/Medicaid/indigent patients by two days within one year.
2. Reduce length of stay in high volume medical DRGs for Medicare/Medicaid/Indigent patients by three days within one year.
3. Reduce clinical laboratory and radiology utilization by 25% within two years.
4. By the end of one year, ensure all inpatients are seen by the discharge planner or have a discharge plan designed by staff nurse at least 24 hours prior to their discharge.
5. Within the next six months, identify respite care needs of the community and develop appropriate action plan.
6. Within six months, reduce denials from third-party payers for inappropriate admissions and unnecessary continued stays by 50%.
7. Reduce the percent of asthma patients readmitted within 45 days by 75% within two years.
8. Within the next six months, improve by 20% the advancement of medications from parenteral to oral route when patients are able to tolerate oral intake.
9. Within one year, reduce by 25% the number of unnecessary pre-op days of hospitalization.