Department redesign frees up CMs to coordinate care

UR nurses review patients from all payers

A redesign of the care coordination department at Riverside Medical Center in Kankakee, IL, assigns utilization review tasks to dedicated nurses, freeing up case managers to spend more time with patients and develop a close working relationship with physicians to facilitate smooth and timely progression of care.

“We were doing an excellent job with an average length of stay of 3.76 days. But we knew that with the new regulations coming from the Centers for Medicare & Medicaid Services [CMS] and the increase in auditors scrutinizing our records, we had to work to improve what we were doing for the future,” says Brenda Menard, BSN,MHA, CCM, CMAC director of clinical resource management for the 280-bed hospital.

“We knew we had to adjust the way we think about the plan of care and take a holistic approach that includes physicians, nurses, therapists, the lab, radiology—all entities providing care—to plan for the day, plan for the way, and plan for pay to provide a safe discharge,” she says.

The hospital has three utilization review nurses who are assigned by unit and review patients with all types of payers, including commercial, Medicare, Medicaid, self-pay, and Veterans Administration, utilizing clinical criteria. Each morning they receive a report from the team leaders on the units and review the carts as needed, and share the information with the case managers. The hospital’s post-acute care coordinators, two non-clinicians with coding backgrounds, handle faxing information needed for referrals to nursing homes and home health services and set up durable medical equipment and other post-acute services. A nurse calls the post-acute facility or service agency and provides a thorough clinical report.

The case managers don’t see every patient but concentrate on the patients who need it, based on criteria developed by the care coordination department and referrals from physicians and the utilization review nurses. The case managers refer patients such as those with multiple comorbidities and trauma who have comprehensive discharge needs to social services and work with the social workers on the discharges. At the end of each day, the case managers enter potential discharges into the Pending Discharge List in a drive that is accessed by all entities in the hospital. “The staff is alerted to address the issues of patients who are leaving the next day. In this manner, all the ancillary departments know how to prioritize and complete what the patients need early in the morning to promote timely discharges,” she says.

The facility is moving toward having nursing handle the non-complex discharge planning, Menard says. The hospital presented a 12-hour teaching session for the team leaders and managers to help them understand the new role for nursing. “They were already doing a lot of discharge planning and are responsible for the discharge teaching,” Menard says.

As part of the process redesign, case managers now are assigned to surgeons and primary care physicians instead of by unit. They began by visiting the physician offices and re-introducing themselves. “They explained that the case managers are partners with the physician in ensuring that their patients’ transition-in-care needs are met. Nurses work 12-hour shifts and the physician may not see the same nurse two days in a row. The case managers are there every day in the hospital to work with the physicians to facilitate tests and procedures, and streamline their patients’ post-acute needs,” she says.

During their visits to the orthopedic surgery offices, the case managers discussed the importance of having documentation in the medical record to support the surgery. “We told them what documentation we require to demonstrate that the patient has failed outpatient modalities and that the procedure is medically necessary. Otherwise, the surgery will be canceled. It was hurtful at first but the physicians and surgeons understand that neither they nor the hospital will be reimbursed. We told the physicians that we know that all they want to do is take care of their patients but that we are the voice of the payer as to what they will reimburse for or deny,” she says.

The care coordination department began four years ago to educate the surgeons and attending physicians about medical necessity and the importance of complying with Medicare rules and regulations. “We explained how the hospital was losing money when treatment was denied and showed them documentation on how they should proceed. Now, they are beginning to understand and it’s very exciting,” she says.

Before redesigning the care coordination process, the hospital hired a case management consulting firm to review the entire patient care process to determine what needed to be done.

“I had been trying for three years to get the administration to hire utilization review nurses in the emergency department at night. The consultant showed them the numbers and the request was approved. Sometimes, it takes an outsider to speak to the administration in a way that it clearly understood,” she says.