Critical Path Network
Culture change turns hospital system around
Process ensures that patients meet medical necessity criteria
A few years ago, Christus Santa Rosa Hospital in San Antonio was $80 million in the red and was compliant with medical necessity and appropriateness of care criteria only 62% of the time, according to audits by the hospital's quality improvement organization (QIO).
That was 2001. In 2008, the hospital system received a 92% compliance rating and was named one of the best 50 hospitals in the nation by HealthGrades for the sixth year in a row. At a 6.8% rate for converting patients from observation to inpatient status, the hospital is well below the national benchmark of 25%.
Turning the hospital system around required a complete culture change in the hospital and in the community, says Roxanne Jenkins, RN, regional director, care management/accreditation compliance for Christus Santa Rosa, a nonprofit, faith-based health system with four facilities in southern Texas.
"We provide a large charity benefit. However, the community's perception was that we should provide all of the charity care without regard to the cost of care. We had many patients who didn't meet admission criteria and a lot of social admissions. We had to educate the community that 'no margin, no mission.' That is very difficult for us, as our mission is to extend the healing ministry of Jesus Christ," she says.
When Jenkins arrived at the health system's flagship hospital, Christus Santa Rosa, in 2001, there was a lack of a care management program and no method for determining medical necessity or appropriateness of care.
In addition to caring for indigent patients, the hospital system was subject to a quarterly review by the QIO and was only 62% compliant, which meant that the hospital had to pay back the erroneous reimbursement in 38% of cases.
"We needed a gatekeeper up front so we would get the patient in the right status at the beginning and wouldn't have to clean up on the back end. Many hospitals put their gatekeepers in the emergency department, but we are a multisite hospital, and the cost of putting someone in the emergency department or admitting department at each site would not be beneficial," Jenkins explains.
Patient intake center makes difference
A key to the hospital's success was the creation of a patient intake center, staffed by experienced RN case managers with backgrounds in acute care case management who are responsible for reviewing the admission and the status of every patient admitted to the four facilities in the health system. The patient intake center, located at Christus Santa Rosa, is staffed 24 hours a day, seven days a week.
"We couldn't just open the patient intake center. We had to make a lot of operational changes and change the culture of the practice at the hospital and that took a lot of work up front. This could not have happened without the full support of the administration and the corporate leaders," Jenkins says.
The hospital administration appointed an interdisciplinary revenue cycle/denials team with representatives from financial services, admission and registration, and care management and added ad hoc members if there was an issue that they could affect.
The team started by analyzing data for opportunities to change or improve the processes.
The team analyzed denials and drilled down to determine the reasons for the denials. It sorted denials by physician, service line, diagnosis, admission status, and level of care.
"We started trending and identifying patterns and opportunities to change or improve processes. The administration was amazed by our findings. We knew from our QIO's quarterly review that many patients did not meet admission criteria and that we had far too many one-day stays," Jenkins says.
Many of the denials were because the admission didn't meet medical necessity criteria or because the status was inappropriate.
In the past, physicians often allowed patients who were ready for discharge on Friday to stay over the weekend or admitted them for three days to meet the Medicare criteria for transfer to a skilled nursing facility.
"We also found that we were experiencing a high number of one-day stays, some of which should have been outpatient procedures," she says.
At the time, doctors would routinely admit indigent patients to Christus Santa Rosa for outpatient diagnostics if they knew the patient couldn't pay.
"We were losing a lot of money this way. Now we offer to assist patients in scheduling the outpatient diagnostic procedure and offer financial counseling and charity care," Jenkins reports.
Drilling down
The team drilled down and discovered that other hospitals in the community were transferring their unfunded patients although the referring hospital could provide the same services and the same level of care.
"There was dumping going on. That needed to cease immediately," Jenkins says.
One of the main facilities is in downtown San Antonio where there are a lot of homeless patients. Many homeless patients would come to the hospital when it was cold outside and get a bed and meals.
"We wanted to do what's good in our hearts but we are a health care facility and we need to take care of those who are suffering from health care conditions and who meet the criteria," she says.
Jenkins made a proposal to leadership for changes in how the hospital operates.
"We knew that we needed to meet national benchmarks and institute evidence-based practices, and to do that we had to change physician practice patterns and the culture of thinking that the hospital could be everything to everybody no matter what they needed," she says.
In addition to creating the patient intake center, the hospital enhanced and structured the inpatient care management department to follow up on admissions and ensure that patients continue to meet inpatient criteria and move safely and appropriately through the continuum of care.
The hospital's computerized admissions system allows the patient intake center to notify the case managers of all admissions that need a follow-up.
The team also drilled down on organizational reports to review denials, one-day stays, and observation patients to find the opportunities that might impede them from reaching their goals and to develop procedures to overcome the barriers.
"We tried to foresee every barrier and eliminate that barrier. When we had an inappropriate admission, we looked at what we could do to prevent it from happening again," she says.
"We spent months communicating with and educating the physicians and their office staffs, the hospital staffs, and the referring hospitals about our new process and the reasons for it. We put our changes in a positive light for physicians, telling them that we wanted to institute best practices and to help their patients get the care they need," she says.
The hospital team invited the office managers and nurses at physician practices to lunch to promote a smooth admission process between the offices and the hospital and followed up by delivering baskets of cookies and fruit to the offices along with Rolodex cards with the phone number of the patient intake center.
The team offered continuing education credit "lunch-and-learn" sessions for the physicians. The information provided on integrity and compliance met the requirements for the physicians' CME credits on ethics.
"We spoke at every medical staff committee, focusing on best practices, rather than making changes to affect the hospital's financial health. We enlisted their help in becoming the best facility in the area. That's what helped change the culture," Jenkins recalls.
The hospital compiled data that showed which physicians were admitting patients whose cases were not reimbursed due to medical necessity and/or patient status and enlisted the aid of physician champions from the performance improvement teams of each facility to educate the physician outliers one on one.
"We informed the physicians of the scrutiny we were getting from regulatory agencies and provided education on how this would affect our quality outcomes now and in the future. We wanted to partner with them so it would be a win-win situation for all of us. The physicians were reluctant at first, but many of them have expressed their gratitude now that CMS [the Centers for Medicare & Medicaid Services] is looking at their billing as well," she says.
(For more information, contact: Roxanne Jenkins, RN, Regional Director, Care Management/Accreditation Compliance for Christus Santa Rosa. E-mail: [email protected].)
A few years ago, Christus Santa Rosa Hospital in San Antonio was $80 million in the red and was compliant with medical necessity and appropriateness of care criteria only 62% of the time, according to audits by the hospital's quality improvement organization (QIO).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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