Re-engineered discharge, UM process cut LOS
Re-engineered discharge, UM process cut LOS
Daily DRG reports key to reducing Medicare losses
Faced with changes in Medicare reimbursement and the growing impact of managed care, St. Frances Cabrini Hospital in Alexandria, LA, re-engineered how it moved patients through the continuum of care and reorganized discharge planning and utilization management (UM) functions. As a result, Medicare losses and lengths of stay went down.
Two years after the re-engineering process began in 1992, the hospital’s overall average length of stay was four days, down from 11, says John Brothers, MSW, MHA, who oversaw the process in his former job as director of social work, UM, and patient relations. "Our CFO at that time said it was the most exciting thing he had ever seen happen at that hospital."
The hospital identified several key problems that prompted the turnaround:
• Reimbursement.
Patients were not being efficiently managed through the health care continuum, resulting in inadequate acute care reimbursement.
• Inadequate cost accounting.
With certain DRGs, such as coronary artery bypass and congestive heart failure, the hospital’s cost of providing the care was greater than the reimbursement it was receiving.
• Poor utilization.
Length of stay was longer than it should be, both overall and for specific DRGs.
• Coordination of efforts.
Discharge planning was a function of the Social Work Department, but there was also a separate Utilization Management Department. The two departments reported to different administrators, and communication was limited. "There seemed to be more a battle between the two, as opposed to their working in tandem," Brothers notes.
"We recognized a need to address the issues of reimbursement and to move the patients from the acute care setting as soon as medically reasonable and get them to an alternative level of care," he explains. "That was challenging in that the community lacked some of the resources to complete the continuum, and some patients were forced to leave the community to receive certain types of care, such as ventilatory management."
Getting outside help
The hospital hired Sharon Baschon, a utilization and case management consultant with The Baschon Group in Durham, NC, to help determine areas that needed improvement, Brothers says. With Baschon’s assistance, the hospital made the following seven changes:
1. Social Work and Utilization Management began reporting to the same administrator, the chief financial officer.
2. The UM department began receiving daily reimbursement information on patients, including the patient’s name and age, the insurer, the DRG, the cost of care to date, the expected reimbursement, and the percent of the reimbursement used to date.
3. The hospital began "case finding" identifying potential discharge problems. This became the task of several employees, including social workers, UM nurses, case managers, and unit directors, with social workers bearing the primary responsibility.
4. In addition to the routine discharge planning meetings being held on the individual units, weekly utilization management meetings were established. These Thursday morning meetings were attended by utilization managers, social workers, case managers, unit directors, the chief medical executive, the CFO, and sometimes the CEO, as well as representatives from home health, rehab, skilled nursing facilities, and long-term acute care. On occasion, physicians who served on the Utilization Management Committee would attend.
"All patients with discharge problems or potential discharge problems were discussed," Brothers says. "Recommendations were made, and a follow-up report was expected at the next meeting. The unit case managers and the unit directors were critical to the success because they knew their patients and were held accountable for their units. The UM secretary took notes and made sure the appropriate person would follow up."
The CFO supported the meeting and encouraged participation, describing it as the most important meeting the hospital held, Brothers adds.
5. The staff became stewards of hospital resources. "They were aware of reimbursement in all levels of care and learned to maximize the reimbursement by moving patients appropriately," he says. "Some DRGs were case-managed, which helped to reduce the losses. Information was available on physician utilization, so we knew which physicians to target and work with in moving the patients."
6. Physicians were provided with a DRG work sheet on the patient’s chart, making them aware of the reimbursement status of the case.
7. The staff were responsible for being patient advocates. Emphasis was put on upfront communication, so patients and families had the proper expectations and understood why things were happening as they were.
"This was an evolutionary process that took several years and is constantly being revised to meet the needs of the patients," Brothers points out. "Changes did not come easily, nor did they come quickly."
Physician resistance a problem
Some physicians felt the procedure was a challenge to their authority, and they resented staff making recommendations for their patients, he notes. When a physician did not respond to the staff recommendation, the issue was referred to the chief medical executive, who after becoming familiar with the case would discuss it with the physician, Brothers explains.
"Sometimes this was accepted, and sometimes it was not," he adds. "There were times when we backed down because of the politics involved."
Getting the buy-in of physicians was crucial and took time, he points out. "We chose people who had gained their trust and respect and put them in the position of communicating with the physicians," Brothers says.
Communication at all levels was critical to the success of the program. "The meetings we held were not threatening if they became so, we would back off and change directions," he notes. "It was important to know individual limitations and rely on each other to resolve issues."
Change process continues
In line with the evolutionary process Brothers describes, St. Frances Cabrini has changed several aspects of its continuum of care since he left the hospital, explains Angela Baudin, RN, medical-surgical case manager at the hospital.
About a year ago, the management structure of the entire hospital changed, with "clusters" organized around the type of medical care provided. For example, Baudin, as a medical-surgical case manager, reports to the director of medical-surgical services, while another case manager might report to the director of cardiovascular services. There also is a maternal-child cluster.
The hospital no longer has a chief financial officer, and the functions of the case management and social work departments have changed, she says. Case managers do utilization review and discharge planning, making rounds with physicians, reviewing charts, and providing clinical information to all third-party payers.
"Before, [employees performing] utilization review didn’t have patient contact but just did chart reviews and moved patients to different levels of care," Baudin explains.
Social workers handle initial counseling of patients with critical diagnoses; discuss patients’ financial concerns; deal with all kinds of abuse cases, including substance abuse; work with initial nursing home placement; and provide information on advance directives, Baudin adds.
[Editor’s note: For more information, contact John Brothers, administrator, Dubuis Hospital for Continuing Care, 2830 Calder Ave., 4th Floor, Beaumont, TX 77702. Telephone: (409) 899-8156.]
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.