Critical Path Network
Collaboration reduces LOS, improves outcomes
CMs have close relationship with receiving facilities
Strategies that include developing close relationships with post-acute providers; meetings to explore options for extended-stay patients; and collaboration between nurse practitioners, hospitalists, and the interdisciplinary care team have helped Catawba Valley Medical Center in Hickory, NC, reduce the number of patients who stay more than 15 days.
The number of patients who have been in the hospital more than 15 days dropped from an average of 42 per month in fiscal year 2006 to 40 per month in FY 2007. So far in FY 2008, the number is running about 39 per month.
"It all comes down to communication with members of the treatment team and developing a close relationship with our discharge resources," says Mary McDaniels, RN, MNA, administrator of clinical resource management.
The multidisciplinary team on each unit discusses long-stay patients during the daily team meeting and brainstorms on discharge options. The morning rounds are conducted by the case managers and social workers and include representatives from the therapy department, a dietician, the unit-base pharmacists, one or more hospitalist, and the charge nurse in the critical care unit. Someone from the hospital's spiritual care department attends rounds on the critical care units.
The hospitalist team of physicians and nurse practitioners is a vital part of the interdisciplinary team, serving as a physician resource for all the patients on the unit, McDaniels says.
"We found that we were missing an important link in the team rounds and that was the patients' physicians. They are so busy that they don't have time to attend the meetings. We asked the hospitalists or their nurse practitioner to attend morning rounds for the entire floor, including being an expert resource for the team on the patients of other physicians," she says.
In addition, the hospital holds extended-stay meetings once a month to look at options for patients who have been in the hospital for 10 days or more, she says. All of the social workers and case managers attend the monthly meetings and bounce ideas off each other on how to handle long-stay patients.
"What works for a patient on one unit might not work on another unit, but often it does. They update each other on community resources and which agencies or facilities were able to care for a particular type of patient," she says.
The hospital integrated its hospitalist program with case managers several years ago, resulting in a drop in length of stay. The program has been so successful that the hospital added two nurse practitioners last year and two additional hospitalists in March.
The hospitalist program provides an admitting physician for patients who don't have a primary care physician or those who have a primary care physician who does not admit patients to the hospital.
Working with the hospitalists has helped facilitate patient throughput, McDaniels says.
"It helps a lot with communication. The hospitalists are the go-to physicians if we have questions. If we are not sure about something, the case managers check with the hospitalist before taking it to the attending," she says.
"It's all a matter of communications. The hospitalists are there during rounds but the specialists come in and go. The case managers can call on the hospitalists for help and guidance at any time," she says.
At Catawba Valley Medical Center, case management staff are assigned by unit and service line.
RN case coordinators are assigned to patients with complex needs. If a patient is transferred to another unit, the case coordinator may follow the patient or turn the case over to the case coordinator on the receiving unit, depending on his or her caseload.
The RN case coordinators partner with social workers to handle discharge planning for patients with complex psychosocial issues. The nurses determine which patients need help with both social and medical issues.
"Social workers look at the patient from a perspective that other health care professionals just do not have. Many times, nurses and physicians focus on the disease and treatment plan. The social worker helps remind the team that we are caring for a whole person and family," McDaniels says.
Registered nurse specialists handle utilization review and communicating with the insurance companies and work with the hospital business office staff to coordinate denials management. The UR specialists work on the front end to assure that medical necessity is being met. When a denial occurs, they assess the clinical data to determine if an appeal would be successful. The business staff follow through with the appeal.
The case management team also includes two case managers dedicated to core measures who review the records on all units to make sure the documentation is accurate and complete.
The hospital has two nurse practitioners on staff who work with the hospitalists to help move patients through the system and act as a resource for the case managers and nursing staff.
"The nurse practitioners are a great bridge between the floor nurses and the physicians," she says.
The case management department's close working relationship with post-acute providers in Hickory and other nearby cities has helped move patients through the continuum in a timely manner, McDaniels says.
"Because of our close relationship, we know which home health agencies can manage the care of complex patients and which diagnoses they can handle best. Our staff are knowledgeable about skilled nursing facilities in the area and what services they can provide to our patients," she says.
When there are complex patients who can go home with home health, the case managers ask the home health agency to visit the hospital and evaluate the patient to make sure that they have staff equipped to handle the patient's care.
The case management department has invited staff from the long-term acute care hospitals (LTACH) in Charlotte, Winston-Salem, and Asheville to educate them on what criteria patients need to meet for admission to their facilities.
"We don't have a LTACH in Hickory, but these cities are located less than two hours away, which is fairly convenient for our families. By working with the staff at the LTACHs, we have been able to move some of our complex patients to their facilities," she says.
The case management team works closely with skilled nursing facilities in the area to facilitate care for patients after they are transferred.
For instance, if a patient with a complex wound is going to be transferred, Catawba Valley Medical Center's wound care specialist writes out the plan of care in detail and invites the charge nurse from that facility to come in and walk through the dressing change. The wound care specialist follows up with the nursing home and, in some instances, visits the patient to oversee the care.
As part of the hospital's efforts to ensure coordinated care across the continuum, the hospital staff facilitate distribution of discharge summaries for the primary care physicians of patients who are seen by the hospitalists.
"We work on a quick turnaround time. Since the physicians who see these patients in the community are not seeing them in the hospital, we feel like they need to know as soon as possible what medication their patients are on, what happened during their stay and discharge," she says.
Their efforts have helped create a good relationship with the primary care physicians in the area and facilitates the exchange of information when the patients are hospitalized, she says.
(For more information, contact Mary McDaniels, administrator of clinical resource management, Catawba Valley Medical Center; e-mail: [email protected].)
Strategies that include developing close relationships with post-acute providers; meetings to explore options for extended-stay patients; and collaboration between nurse practitioners, hospitalists, and the interdisciplinary care team have helped Catawba Valley Medical Center in Hickory, NC, reduce the number of patients who stay more than 15 days.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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