Status management cuts observation patients, LOS
Case management position created
Faced with an increasing number of patients in observation status, Brandon (FL) Regional Hospital began an observation management process that resulted in a 16% decrease in observation patients and a 27% drop in observation length of stay in just one year.
A key component of the process was to create positions dedicated to observation management and remove that responsibility from the unit-based case managers, says Jacquelyn Paynter, RN, MPH, director of case management for the 367-bed hospital.
"When case managers are responsible for a lot of different tasks, they can't focus on all of them at once. Our hospital admits 21,000 patients a year. Unit-based case managers have a patient load of 25-30 and there may be two or three observation patients among them. The case managers have heavy discharge planning and placement responsibilities and were not able to effectively concentrate their efforts on patient admission status," she says.
The hospital began the new process in 2006 when analysis showed that the percentage of patients in observation was escalating each year and, concurrently, the number of days the patients spent in observation was continuing to increase.
Three factors at play
A root-cause analysis determined that the problem boiled down to three major factors: the tendency of payers to steer patients toward observation, practice patterns of physicians, and the way the case management staff were organized.
"We knew that we had to reorganize the structure of case management. When it came to care coordination, we were treating our observation encounters like all other inpatient encounters. Now we operate on the principle that if we are going to keep them more than 24 hours, they need to meet inpatient criteria. Otherwise, we need to clear them to the outpatient level and get them out of observation," she says.
The department created a new assignment — observation case manager — a dedicated case manager who is responsible for managing observation patients throughout the entire hospital. The position is filled from 7 a.m. to 7 p.m. seven days a week.
At the same time, the department assigned dedicated case managers to perform the initial medical necessity review of newly admitted patients.
"This assignment achieves increased staff proficiency and timeliness of the initial reviews," Paynter says.
The case management physician advisor reviews every patient who doesn't meet inpatient criteria and every patient who is in observation more than 24 hours.
If the patient's condition doesn't meet textbook criteria, the physician advisor sometimes can convert the patient to inpatient status, based on his medical knowledge of comorbidities, appropriate treatment, and other factors.
"We have built checks and balances into the process to ensure the proper admission status on a day-to-day basis," Paynter says.
The case managers who review for medical necessity determine if patients meet criteria for observation vs. inpatient criteria and document it. If an observation patient meets admission criteria, the case manager uses a protocol approved by the medical staff that allows them to convert the patient to inpatient status. The case manager also contacts the attending physician to obtain additional clinical information or to change the patients' admission status to observation if they don't meet inpatient criteria.
"Once the patients are assigned to observation status, the observation case manager is responsible for them and her role is to facilitate the timely execution of a plan of care and discharge," she says.
The observation case manager concentrates on getting the observation patients the services they need and getting them out of the hospital.
"We're being paid for just 24 hours of care by the private insurers. We don't have a long time to get it right during the course of stay," she says.
Paynter, the case management supervisor, the physician advisor, and the observation case manager conduct an observation case conference several times a day and review the charts of all patients who are in observation. They look at why the patients are in observation, the number of hours since they were admitted, why they have been in the hospital for that length of time, what should happen next, and how they can be discharged quickly and safely.
The observation census also is reviewed at the daily bed placement meetings, attended by all department heads. This allows administration, nursing, and ancillary departments to take action regarding barriers that impact on throughput for patients in observation status, Paynter says.
"When we review the census the first thing in the morning, the case manager starts to hammer away at it. We look for the low-hanging fruit, those whose admission status can easily be changed, and start there," she says.
For instance, if a patient came in with anemia, has received a blood transfusion, and his laboratory values still are abnormal, the case manager knows she can get that one changed to inpatient status.
The observation case manager periodically reviews the patient record, looking for roadblocks in the system that may be holding up the patient's discharge or admission as an inpatient and acts as a facilitator.
For instance, when a patient who comes to the ED complaining of chest pain is placed in observation status, the attending physician typically orders a cardiology consultation and a stress test.
The case manager monitors the situation and, if necessary, prompts the cardiologist to evaluate the final stress test imaging result as soon as possible and reminds the attending physician to review the consultation and either discharge the patient or admit him or her.
Patients in observation do not necessarily present with a clean, straightforward episode of care and can be as expensive as patients who are admitted on the inpatient level, she points out.
For instance, when patients in observation status have complaints in addition to the reason they're in observation, the attending physician is likely to order additional tests and consultations.
"When physician prescribing or treatment patterns do not change based on the level of care, it places a burden on the hospital from a financial standpoint because the hospital's reimbursement is based on a flat observation payment," she says.
The observation management process has resulted in case managers who are highly skilled at determining admission status, Paynter points out.
"If you want to optimize inpatient vs. observation status, you have to have people who are good at it and they get good at it by focusing on the job," she says.
(For more information, contact Jacquelyn Paynter, director of case management, Brandon Regional Hospital; e-mail: [email protected].)
Faced with an increasing number of patients in observation status, Brandon (FL) Regional Hospital began an observation management process that resulted in a 16% decrease in observation patients and a 27% drop in observation length of stay in just one year.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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