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Case managers at Arnot Ogden Medical Center in Elmira, NY, use a combination of high-powered software systems to ensure the proper placement and care of patients — and documentation of their decisions occurs in the computer, says Tina Davis, RN, MS, CNS, senior director of continuum of care.
The software is an interface between Health Data Management (HDM), a 3M software that examines coding, and InterQual software, a systematic approach to determining who should be an inpatient, she notes. "As the case managers review a case, they use HDM to code the patient to come up with a concurrent working DRG [diagnosis-related group]. After the patient is coded, the case managers access the InterQual program to identify if the patient meets the criteria for admission."
The beauty of combining the two programs, Davis says, is that the case manager reviews the chart and documents the results of that chart review in the computer.
"The system is an actual database that we can run reports from," she adds. "We run reports to identify how many patients meet the admission criteria, and we can compare the results [according to] physician and payer. This information is shared with the hospital’s utilization review committee to act upon."
Since many insurers use InterQual criteria to determine whether, for example, a patient should be an inpatient or an observation patient, she adds, the process allows hospital to make the same determinations, and to have documentation should it have to fight a denial of reimbursement.
Arnot Ogden’s case managers use a Patient Review Instrument (PRI), a tool that is unique to the state of New York, to identify what level of nursing home placement is appropriate for the patient, Davis says. (See chart.)
Soon after Medicare began using resource utilization groups (RUGs) in 1986 to determine reimbursement for nursing home placement, the PRI was developed by the Professional Standards Review Council of America (PSRCA) to facilitate that process, she explains.
Nursing homes use the PRI for reimbursement purposes, Davis adds, while hospitals and community agencies use it to identify the level of care the patient will need.
"When the case manager, the social worker, the physician, and the family all identify that the patient can be moved to an alternate level of care, the case manager fills out a PRI form for the patient and comes up with a RUGs classification score," she says. "Depending on the score, we know whether the patient is a nursing home patient or an adult home care patient."
In screening for admission to their facility, nursing home officials look at the PRI score to see what level of care the patient will need, Davis points out. "It’s a neat classification system, which helps us understand exactly what the patients’ needs are — if they’re clinically complex, need rehab, and so forth."
The state requires an eight-hour training class — which all of Arnot Ogden’s case managers have attended — for those who complete the PRI, she says. Those who are certified receive a card with an identification number, and that number must be written on each PRI, which is then signed by the person completing it, Davis adds.
[InterQual Products Group, Marlborough, MA, is a subsidiary of McKesson-HBOC. For more information on the system, call (800) 582-1738 or visit the Web at www.InterQual.com.]