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Protocols, preventive measures often help
There’s no doubt about it: Managed care is not going away, and insurers are likely to put more and more pressure on physician practices to cut costly hospitalization days.
Practices with a few years of experience in dealing with managed care have come up with ways of cutting inpatient days without affecting quality of care. Here are some of their strategies:
• Standardization of care.
Cardiology Associates in Mobile, AL, is working on setting up practice protocols and guidelines for handing the major diagnoses that make up 80% of its caseload.
"Although each person is an individual, it’s possible to standardize a lot of care. If all the doctors are doing the same thing and there is a plan for treating that diagnosis, it has the potential of shortening the length of stay," says Vance Chunn, FACHE, executive director.
For instance, if a physician is seeing another physician’s patients, he or she loses continuity and efficiency if he or she doesn’t know exactly what treatment the patient has been receiving, Chunn says.
"We’re not looking at cookbook medicine, but we are putting in place guidelines to maximize patient flow," Chunn says.
The practice’s physicians are using practice protocols from the American College of Cardiology and fine-tuning the protocols to meet the needs of their patients.
• Utilization review measures.
Many practices hire a nurse who acts as a case manager, reviewing inpatient charts and suggesting alternatives to inpatient care when appropriate.
"The physician may be aware of how patients are doing but may not know all of the alternatives available to them," says Barbara Gunder, MA, practice administrator at the Salem (OR) Clinic, where a registered nurse acts as inpatient reviewer.
At the Springer Clinic in Tulsa, OK, a nurse and the physician who heads the patient care committee make rounds on every patient in the hospital to make sure things are moving along and that the patient is discharged as soon as reasonably possible, says Rick Callis, administrator of the 75-physician group.
If the physician and nurse feel the admission may not be justified, they visit the attending physician, go over the details of care, and discuss options for shortening the length of stay.
Cardiology Associates is in the process of hiring a utilization management nurse to work with physicians on managed care contracts, particularly capitated ones, to help the practice get a handle on managing cost and length of stay. Job duties include making sure all the data the physicians will need are included in the patient chart, and getting copies of the results of tests and procedures performed by the referring physicians so the tests won’t be duplicated.
• Transferring patients to a less intensive part of the continuum of care, such as a skilled nursing facility (SNF), or discharging them to home with home health.
The Springer Clinic makes extensive use of SNFs in lieu of hospitalization. For instance, total knee and total hip replacement patients may be transferred to the SNF when they are medically stable but not yet ready to function at home alone.
"We’re starting to see more direct admissions to SNFs for patients whose care can be managed effectively in a less intensive setting," Callis says.
In another example, a pneumonia patient could be treated in a SNF at a cost per day that may be 30% of hospital costs because of lower overhead.
• Taking a proactive approach to keeping patients out of the hospital.
"The biggest factor that impacts length of stay is keeping patients out of the hospital. We identify diagnoses that are a significant cost factor and try various interventions to help keep those patients healthy," Gunder says.
For instance, hospitalization of chronic obstructive pulmonary disease patients dropped by 40% in a year after Salem Clinic provided patients with an eight-week course in managing their symptoms.
With chronic conditions such as asthma and diabetes, appropriate screening and blood sugar monitoring help patients avoid complications that could result in hospitalization, says Michael Fleischman, CHC, of Gates Moore, an Atlanta-based health care consulting and accounting company that specializes in medical practice management issues.
The Springer Clinic conducts a nursing assessment on all Medicare risk patients. If the nurse identifies any chronic condition that needs monitoring or significant health problems that should be addressed, the patient comes in for a physician visit.
• Use of ambulatory settings instead of hospitalization.
An increase in outpatient treatment is a major factor in declining inpatient lengths of stay, reports Paul Presken, product manager for research and development at the Sachs Group. Laparoscopic removal of gallbladders on an outpatient basis is one example Presken cites. In other instances, physicians are now scheduling cardiac catheterization on an outpatient basis a few days before surgery in some advanced managed care markets.
"Managed care has accelerated the move to ambulatory settings and adoption of newer technology," he adds.