Sutter access nurse targets unscheduled admissions
Insurance, level of care scrutinized
A patient access nurse charged with getting a handle on unplanned admissions at Sacramento, CA-based Sutter Health is working collaboratively with case managers and proactively with referring physicians to ensure proper patient placement.
"These [case managers] are nurses I can go to when dealing with cases that I think can go to a level of care other than acute," says Barbara Kortes, RN, who is stationed in the case management office at Sutter General Hospital, where an initiative begun in June 2005 as a pilot project has been extended to all adult services at both hospitals.
At Sutter General and at the organization's larger facility, Sutter Memorial, a patient access nurse has been designated to streamline the admission of unscheduled patients, while at the same time controlling access so that only appropriate patients are admitted.
Working in the same office, Kortes notes, has made it easy to ask case managers about cases in which, for example, it appears that a patient might be headed toward inpatient admission primarily because the family is burned out from providing care at home. "They're available to review the case, [to say], ‘Is it a placement issue? Might we be able to put the patient in a skilled nursing facility?'"
Now that her role has expanded, Kortes says, "there is even more learning and education that goes on."
As a tertiary care provider, Sutter General receives frequent referrals from outlying hospitals, she notes. "Our goal was to try to provide a system that was more user-friendly, a one-stop shop," Kortes adds. "Sutter recognizes that there were multiple ways to access the system, and felt it was important to [reduce that] to one or two numbers. We've worked hard to have any requests funneled back to the patient access nurse."
In the past, a physician at another hospital who wanted to refer a patient to a Sutter specialist would call that physician directly and say, "‘Let me tell you about my patient,'" says Kate Tenney, RN, manager for case management at Sutter General. The receiving physician would OK the transfer and someone would call the patient access nurse to let her know the patient was coming, she notes. "We would find out the next day that the patient's insurance plan is contracted with another facility or with a county program that won't pay, and that the transfer shouldn't have happened."
Now the nurse is checking insurance and health plan status, consulting InterQual criteria for level of care, and questioning referring physicians before a patient is admitted, adds Kortes.
If the patient being referred is coming from another facility's emergency department and says that he or she is a Sutter patient, she says, "we're validating that information. If it's a Medicare patient who needs to have a procedure that the [referring] facility can't do, we're asking if the person can go to another facility [affiliated with the referring hospital]."
In the case of a patient who needs emergency care that can't be provided by the referring facility, however, "we're under regulations not to ask any questions, but to provide that care if physician and bed are available," adds Tenney. "If the patient is already stabilized, we're free to ask more questions, but we're very careful to make sure we're meeting EMTALA requirements."
In some instances, Kortes explains, the first call regarding an unplanned admission comes to the bed control office, based in the business services department, where clerical staff take down the initial information — diagnosis, admitting physician, contact number, and the type of bed (inpatient or observation, for example) that is being requested.
"At that point, I get notified, and I call the physician back and review the case with him," she continues. "I also have access to patient records on-line, and at that time I will try to get a quick history — whether the patient was here last week, or whether we've never seen the person before. It gives me more information when I'm talking to the physician."
Meanwhile, Kortes says, she is using the InterQual reference manual to determine if the patient meets observation or inpatient criteria, and at the same time asking the physician questions about things such as the person's current blood levels, which tie into those criteria.
If the criteria for inpatient status are met and that is what is requested, she adds, there is no reason to mention that, but if she believes the patient is better suited for observation status, Kortes makes that suggestion. "My experience has been that [physicians] are very receptive."
At that point, she puts in a request to the nursing unit, the charge nurse assigns the bed, and Kortes makes the call back to the physician. The patient comes to the hospital lobby to register or, if too ill to do that, goes directly to the room, she adds.
"At the same time, I'm also doing a quick insurance test," Kortes says. "The physician will say the patient has Medicare A and B, and we're validating that, and also that the person should be coming to Sutter. If that is not the case, I'll be notified by the bed control department, and will let the physician know that the insurance plan is aligned with another health care system and the patient needs to be admitted there. It's really simultaneous."
The other way that a call for an unscheduled admission can come in, she notes, is through a call from the physician's office directly to the patient access nurse. "As we develop a relationship with the physicians," Kortes adds, "we have a pager number that becomes more established, and they call us directly at either of the Sutter hospitals, depending on the services needed."
Sutter General specializes in neurology, oncology, and orthopedics, she says, while Sutter Memorial's focus is on neonatal care, cardiac care, pediatrics, and women's services.
Each time a case is handled successfully by the patient access nurse, the program's success "builds on itself," notes Danielle Corcoran, RN, Sutter nursing administrator. "We're seeing the physicians being much more open. As the patient access nurses become more knowledgeable, [the physicians] are searching out their knowledge. I believe they see [the nurses] as friendly, accessible, and a resource."
At present, Kortes says, she and her counterpart at Sutter Memorial, with relief from a third nurse, perform the patient access duties seven days a week, 10 hours a day, except for two weekends a month. During those weekends and after hours, she notes, the patient access pager is answered by the nursing supervisor, who does the job in addition to her other duties.
There is a budget request in to have a fourth nurse, which will allow 12-hour coverage, seven days a week, Kortes says. "In our busiest times, we want to have a nurse to work just on the placement issues. We're looking to extend our hours into evening."
[Editor's note: Barbara Kortes can be reached at [email protected]. Kate Tenney can be reached at [email protected].]
A patient access nurse charged with getting a handle on unplanned admissions at Sacramento, CA-based Sutter Health is working collaboratively with case managers and proactively with referring physicians to ensure proper patient placement.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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