CM redesign cuts LOS, readmissions

Teams assigned to each unit

Since University Hospitals Case Medical Center in Cleveland, OH, embarked on a quality improvement initiative that included a redesign of the case management process, length of stay has dropped by almost a full day, readmissions have decreased, and the hospital’s performance on 30+ metrics has increased.

The medical center received the 2012 American Hospital Association-McKesson Quest for Quality Prize in recognition of its progress and innovation in quality and patient safety.

In the new case management model, a three-person core team, each with a clearly defined role and a different focus, is assigned to each unit to work together to coordinate care and discharges. Team members include the new role of RN care coordinator, a case manager, and a social worker, says Catherine Koppleman, RN, MSN, NEA-BC, chief nursing officer, University Hospitals Health System and University Hospitals Case Medical Center in Cleveland. University Hospitals Case Medical Center is the academic medical center and hub of the health system, which includes nine hospitals, 22 medical centers, and 200 primary care locations.

“We integrated case management, so it was not a parallel function but was integrated in the interdisciplinary team,” she says.

On the day patients are admitted, the RN care coordinators review the medical record and determine what the patients are likely to need during the hospital stay and at discharge. They assign themselves or one other person on the core team the responsibility of coordinating those needs. “The RN care coordinator know the patients’ discharge needs and assigns the patient to the right role within the core team to manage coordination and transitions to the next level of care,” she says.

The case managers have a blended role of utilization nurse and clinical case manager. They review patients for medical necessity, length of stay, appropriateness of care, and clinical needs, and handle transitions of patients who are returning to an extended care facility or assisted living center. Social workers are responsible for patients in need of psychosocial counseling, those who need financial assistance, and complex patients who are being discharged to extended care facilities for the first time.

The quality initiative was developed by a large group of hospital leaders who worked to ensure a consistent model of care across all hospitals. The team designed a model of interdisciplinary, geographically based care with interdisciplinary teams assigned to each unit by service line.

It’s all about differentiating roles and having people assigned to focus on a sub-population on each particular unit. “The time patients spend in the hospital is so short and the care so intense that we decided to create different roles so everyone on the team is focusing on different things. When we had a separate department of social work and a separate department of case management, the disciplines didn’t necessary work together and sometimes duplicated their efforts. When everyone works together as a team, it works,” Koppleman says.

The three-person core team meets every day for touch-base rounds that take about 15 minutes, during which they discuss the new patients and the plans for the day.

In addition, the entire treatment team holds daily team interdisciplinary rounds for complex patients and those who are at risk for readmission. Depending on the unit, the rounds are held at the bedside or at a conference room. The rounds are led by one of the core team, are attended by clinicians responsible for patient care, and could include physical therapy, occupational therapy, respiratory therapy, pharmacy and others depending on patient needs.

Representatives from the hospital’s home care agency, and case managers from mental health facilities, post-acute facilities, and insurance companies also attend the rounds when appropriate. “Our team works closely with case managers from payers and other providers. It helps to meet people face to face when you are putting together a plan for transition,” Koppleman says.

When the staff determine that patients are at risk for readmission and they don’t qualify for home care, the hospital sends nurses from its home care agency into the home within 72 hours to go over the discharge plan, perform medication reconciliation, make sure the patient has a follow-up appointment with a primary care physician, and answer any questions or concerns. The readmission rate for this group of patients has decreased almost by half since the initiative began, Koppleman says.

“All studies show that if patients have contact with a healthcare professional who goes over their discharge plan within 72 hours of discharge they have less risk of readmissions,” she adds.

The care coordination team tracks the patients on an electronic board that includes the expected length of stay, the probable discharge destination, what ancillary services have been ordered, and what the patient needs for discharge. When a patient is admitted, data are automatically transmitted from registration. The board is managed by the three core team members and other disciplines update the board as they complete their tasks.

The team uses an electronic transfer form, which it sends when patients are discharged to a post-acute facility. The RN care coordinator makes a follow-up phone call to make sure the receiving facility has all the information it needs.

When the hospital began focusing on readmissions in 2009, the teams on each unit received readmission data from their patients. “We gave each team their readmission rate, and the DRGs being readmitted and assigned them to look at the root causes for readmission and come up with ways to reduce them,” she says. Now, when patients are readmitted, the core care coordination team rounds on the day of admission, reviews the cause of the readmission and uses the information to put together a better discharge plan.

The hospital has partnered with extended care facilities and other agencies in the community on readmission reduction efforts. A dialysis center has a care coordinator who follows patients across the continuum and who comes into the hospital to work with dialysis patients and develop a discharge plan with the hospital team. The hospital has made its inpatient medical records available to the dialysis care coordinator to aid in the transitions. The Western Reserve Agency on the Aging has trained coaches on using the Care Transitions Intervention, developed at the University of Colorado, to facilitate transitions. The coaches are being integrated into the hospital’s interdisciplinary rounds when the patients are elderly.

“We are focusing more on the continuum of care and creating smoother transitions. By working with other providers and agencies in the community, we can improve patient care and keep people out of the hospital and the emergency department,” she says.