Critical Path Network

Proactive case management initiatives help cut LOS

Technology, education, support staff contribute

When the case management department at University of Wisconsin Hospitals and Clinics implemented a series of initiatives to improve the throughput of patients, the average length of stay for surgical patients dropped from 7.9 days to 4.6 days and overall length of stay dropped from 6.3 days to 5.1 days including all the outliers.

"We knew that we needed to turn around the patient stay more quickly. On any given day, we weren’t getting patients out quickly enough and sometimes, we had to turn away patients because there were not enough beds," says Barbara Liegel, RN, MSN, director of coordinated care for the Madison, WI, hospital. Her department includes case management, social work, utilization review, and discharge planning.

The hospital, part of an academic medical center, has had case management since the 1990s, but until recently, the case managers concentrated on discharge planning rather than proactive management of patient care, Liegel says. "We changed to a model targeting length of stay and looking at the potential level of care."

The hospital developed a physician advisor role to help physicians understand the importance of moving patients through the continuum and implemented a long-stay management committee that meets weekly to look at ways to facilitate patient discharge.

The support staff who handle referrals and payer contacts were moved to a centralized resource center away from the hospital.

The key to the improvement in patient throughput is the implementation of an automated case management system, Liegel adds.

The hospital uses Canopy Systems case management system, Interqual tools from McKesson, and the Extended Care Information Network (ECIN) for post-acute referrals.

Capacity issues and a goal of supporting better throughput of patients were the impetus for purchasing the case management system.

"It’s bigger than just an automated system. We have buy-in from senior management to provide support to our physician group and to influence the way they practice," she says.

When case managers report for work, they pull their patient census off the computer and begin to see patients. They complete clinical reviews or utilization reviews and assess the patients to see where they are in the continuum and where they need to be in the next few days.

They round daily or every other day on discharge rounds with the physicians, occupational therapists, or physician therapists. The case managers have wireless laptops, enabling them to do their clinical assessments and access any information they may need on the floor.

"Before we had the computerized system, we would get a list of patients and start going to see the patients with no clear-cut idea of whether the patient was in the hospital for the first time or had been readmitted. Everything was handwritten and put in the chart. If I picked up someone’s caseload, I had to go through the entire chart looking for notes and a plan of discharge," explains Sheilah Fields, RN, BSN, MBA, outcomes manager for surgery, oncology, patients at the department of corrections’ facilities, and interventional radiology.

In the past, case managers kept a lot of information in their heads until they had time to document it in the chart. If someone was sick or on vacation, their colleagues had a hard time taking care of the patients’ needs, Liegel adds.

"Now all of us in the case management department can manage any patient in the building because we have all the information at our fingertips," she says.

As the hospital implemented the automated case management system, some case managers were worried that they were going to have to spend a lot of time sitting and working on the computer. "Actually, we’ve been able to see more patients, patient satisfaction has increased, and the length of stay has decreased," Fields says.

At University of Wisconsin Hospitals and Clinics, case managers are assigned to physician services.

"The case managers may have to cross geographic units because not all patients fit on one unit. The physician-based model worked for us. Teaming the case manager directly with physicians on that service has helped us change the physician practices that needed to change to decrease the length of stay," Liegel says. A computerized case management system allows the case managers to track length of stay and outcomes and demonstrate how important it is to move patients through the continuum, she says.

"By measuring outcomes, we can show how we are directly affecting patient stays. It’s helped the department to become more of a professional case management team and has given us more influence in the hospital," Fields says.

The case managers have used data generated by the case management system to educate physicians on the importance of meeting Interqual criteria and the need to move patients through the continuum to free up beds and increase capacity. "We have been able to help physicians understand why meeting Interqual criteria is important so we could better serve patients by meeting the length of stay requirements. We helped them understand that payers are looking at Interqual criteria, and that’s why we need to remove the Foley catheter on Day 2 and not Day 4," Fields notes.

Now that the surgeons understand that moving patients safely, quickly, and appropriately will increase their ability to treat more patients, they often come to the case managers to see if they can shave a day off the length of stay in some DRGs, she adds.

As the census has increased, the hospital’s case mix index acuity level has remained quite high, averaging 1.7 to 1.8. "We continue to get sicker patients and are moving them more quickly. The discharge plan is in the chart and on the intranet so the physician and clinic can find it," Fields adds.

The entire department has gone through quality improvement looking at very specific DRGs or procedures and how they can be done more effectively and efficiently. "Automation helped us set the standard. We couldn’t be doing any of the rest of this without an improved way to communicate," Liegel says.

The hospital’s long-stay committee includes the chief medical officer, fiscal staff, a representative from administration, the legal department, patient representatives on certain cases, and physician advisers. The case managers choose patients for discussion.

The group meets once a week for an hour and usually tackles eight to 10 new cases during each session as well as reviewing the cases presented the week before.

The group initially targeted patients who had been in the hospital 30 days or longer. In the initial meetings, that group was around 55 patients.

Now that length of stay has dropped and the number of patients in the hospital 30 days or longer has dropped below 20, the group is looking at patients who have been in the hospital 20 days or longer.

"As it has evolved, the staff are comfortable bringing up patients they feel have the potential for a lengthy stay. We’re looking at delay issues sooner and not later," she explains.

The fiscal department participates to help support plans of care. For instance, if there is a patient who has no insurance but needs six weeks of bed rest, the fiscal department helps decide whether the staff should keep the patient in the hospital for the six weeks or pay for a stay in a nursing home, freeing up the inpatient bed.

"The staff feel more support because representatives from all parts of the hospital can help solve the issues that crop up in an academic medical center," Liegel notes. Moving the case management support team off-site to a centralized location was another efficiency measure, she says.

The department has been able to decrease the number of support positions by moving them off-site and centralizing them, rather than being on-site and working with the teams, Liegel says.

The Resource Center is staffed by payer specialists and referral specialists who take care of the nonclinical details often assigned to case managers. The payer specialists are assigned by payers and review companies. They make 60 to 70 calls each day, providing information for clinical reviews.

"We evolved an old case manager associate role and centralized it to provide support work for the licensed clinical staff. It has freed up the clinical staff to work within their team rather than making phone calls and faxing, " Liegel adds.

Each clinical practice group is assigned a referral specialist who does work that is delegated by that clinical team. For instance, the referral specialists may be called on to check with a patient’ insurance if the patient needs to be discharged with home health and durable medical equipment. The referral specialists check on nursing home availability and arrange transportation. When a patient who lives outside of Madison is being discharged back to his or her hometown and doesn’t have a primary care provider, the referral specialists check on what clinics are available.

"A lot of work supports discharge planning. You don’t need a licensed professional to do faxing, copying, and telephone work. Much of the work can be done by support people," she says.

Getting buy-in from management for the computer system was not difficult because management realized that it would be a tool to help move patients through the system.

"In the hospital setting, there are a lot of paper processes that are broken," Liegel says. "It comes from years of working in a chaotic environment where sometimes staff has to go where they are urgently needed. In other environments, it’s easy to do flowcharts, but it’s not like that in our environment." The restructuring and adjustment to a computerized case management system was a challenge for members on the clinical team, she adds.

"We were automating the process for employees who have done something manually for 15 to 20 years and asking them to change their work processes. We have nurse case managers and social workers on the team who were reluctant in the beginning but now realize that their practices can be more efficient and can see more patients than they did in the past," Liegel notes.