Critical Path Network: CM redesign: How one organization tackled the process

Outcomes measures indicate solid success

By Kim Pointer, BS, RN, BC CPUM,
Integris Southwest Medical Center,
Oklahoma City

In September 1999, INTEGRIS Health asked 10 employees from their two Oklahoma City hospitals, INTEGRIS Southwest Medical Center (ISMC) and INTEGRIS Baptist Medical Center (IBMC), to redesign certain elements of admitting, case management, medical records, and billing practices. This team of employees met eight hours per day for three months. The changes that occurred in the case management services department at ISMC as a result of the redesign process, are chronicled below:

Background

The original ISMC department had one director who also had duties at IBMC, six full-time RN case managers, two full-time social workers, and one administrative secretary. We provided services via a physician-based model to all acute inpatient areas of our 232-bed facility. Patients were followed from admission to discharge. All admitting physicians were assigned case managers, but not all utilized the services provided by the department. The case managers referred to the social workers as needed. At the time of the redesign, our Medicare length of stay (LOS) was 6.3 days.

Redesign

The department was placed under new senior management with a full-time on-site director.

The position of medical director was transitioned in, and 10 physician members established the utilization management (UM) committee to oversee all aspects of case management and utilization.

A UM plan was written and implemented, and InterQual was selected as the criteria-based standard to be utilized.

In August 2000, we converted to a unit-associated model of RN case manager/social work teams.

The people

The majority of staff chose to remain employed in the case management services department; however, there was some turnover as job roles were redefined and new expectations were outlined.

Additional master’s prepared social workers were hired, and roles and goals for each discipline were developed.

Staff were divided into teams based on experience and areas of interest. Change can be difficult, so the human element was factored into every process decision that was made.

We experienced laughter and tears, as well as many other emotions making the need for team building apparent.

This was initiated and continued to evolve as we implemented and refined new processes.

We attempted to utilize humor while tests were conducted to analyze personality and work preference.

The department developed the "Awesome Team Rules," which defined how we wanted to treat one another.

The most significant thing that occurred, though, was that we each made a commitment to becoming a strong team on behalf of our patients, our facility, and one another.

Current status

Our mission statement for case management services is to assess, plan, coordinate, and facilitate options to meet individuals’ health needs and placement in the appropriate level of care.

This is a collaborative process involving quality, patient satisfaction, cost-effectiveness, and education.

We have a total of seven full-time case managers and six full-time social workers covering case management needs in-house seven days a week.

We also provide on-call services after hours and on weekends. Each hospital unit including the emergency department (ED) has assigned case management staff. We added the positions of clinical database coordinator and database coordinator.

These positions provide clinical and technological training to all staff and perform monthly statistical tracking and trending of data for the UM committee.

We also expanded our administrative secretarial staff by an additional full-time equivalent (FTE).

Current daily staffing is based in general on one RN case manager to 25-30 patients and one social worker to 35-40 patients.

Staffing does fluctuate per census. Our model is designed for case management services to be triggered by the initial nursing assessment, physician orders, care conference input, word of mouth, and by request of patient/caregiver.

Of course, this means we occasionally see every patient, each day depending upon his or her needs.

Daily interdisciplinary care conferences are held on every unit Monday-Friday and are facilitated by the case manager/social work team for that area.

The following information is discussed:

  • current clinical status and clinical goals needed to reach prior to discharge;
  • psychosocial status;
  • discharge plans/options;
  • barriers to discharge.

The department meets weekly as a team with the medical director to discuss problem solving, support issues, and general communication of one another’s needs dealing with various case management issues.

Communication

Our database coordinator developed a web site and a newsletter; we utilize these vehicles for communication to increase awareness of case management throughout the hospital.

Quarterly reports are sent to the top 40 admitting physicians detailing their medical specialty, patient count, average severity of illness (SOI), average LOS compared to the physician, and Medicare GLOS (geometric mean LOS), the percent difference between the two and the opportunity days this represents on a yearly basis vs. potential beds that could be freed up on a daily basis.

That is compared to their status for the same time period one-year prior. Quarterly reports are posted throughout the facility regarding current status on fiscal year goals.

Weekly letters are sent to physicians regarding assigned variance and avoidable days for the previous week. The physicians verbalize appreciation for this timely reminder of delays.

Results/measures of success

Through case management efforts, ISMC reduced and maintained the Medicare LOS at 5.1 days. This is a cost savings to our facility of $3.3 million per year. We decreased our variance days (a day when the patient is safe to be at another level of care) by 23%, and 19% the first two years InterQual was in place and are on target to meet the goals of 15% this fiscal year.

We have since added avoidable days (a delay in the continuum of care but the patient is not safe to leave the hospital).

That results in tracking of potential system issues, i.e., unavailability of operating rooms, throughput issues, etc.

INTEGRIS Jim Thorpe Rehabilitation Hospital (JTRH), also in Oklahoma City, was primarily a social work-driven department, which is commonplace in many rehabilitation arenas.

It was placed under the same umbrella of leadership and adopted the case manager/social work model in July 2002.

Case managers were hired, roles and goals were established, and team building was implemented. At this time, JTRH has realized a cost savings of $1.2 million by reducing their Medicare LOS four days, and putting patient care goals in line with reimbursement changes.

In January 2004, INTEGRIS implemented Canopy, a leading provider of web-based care management solutions.

Wireless laptops were purchased for all staff automating and streamlining their workflow, documentation, discharge planning, and data gathering.

Continuing forward

As we move into the future, both ISMC and INTEGRIS JTRH departments remain excited to serve our patient’s care and resource needs.

We are planning to set goals soon for our next fiscal year. Communication efforts continue to be made upward to the board of INTEGRIS Health, separate hospital boards, and senior management as well as downward to all hospital staff.