EXECUTIVE SUMMARY
DCH Health System’s seven part-time physician advisors perform a variety of tasks to help ensure that the hospitals are appropriately reimbursed and that patients move smoothly through the continuum of care.
- They work with care managers on patient status and also assist with documentation, writing medical necessity appeals, resource utilization, and patient throughput.
- They attend daily transition rounds with the nurses, care managers, and social workers, and participate in weekly long-stay rounds and capacity rounds in the ICU and acute cardiac care.
- The health system brought in experts to educate the physician advisors, sent them to educational symposia, and pays for membership in professional organizations.
At DCH Health System in Tuscaloosa, AL, the duties of the seven part-time physician advisors are growing and run the gamut from reviewing patient status to assisting with documentation improvement to reducing unnecessary resource utilization.
“In recent years, the physician advisor program has grown tremendously. Our hours and our responsibilities have expanded. We’ve gone from mostly conducting status reviews to performing a variety of administrative duties that help ensure that the hospitals in the health system are appropriately reimbursed for the services they provide,” says George W. Nunn, MD, lead physician advisor for the three-hospital system.
Nunn, who was a general surgeon and served DCH Health System as medical director of the trauma service for 39 years, was offered the physician advisor position when he retired. Originally, Nunn worked three hours a day, reviewing Medicare admissions.
DCH Health System draws patients from 14 mostly rural counties and serves as the sole provider for the area, says Carolyn Hamilton, MS, RN-BC, CDDS, CPHQ, corporate director of care management. The system’s flagship hospital, Regional Medical Center, is an academic medical center with 583 beds. Other hospitals in the system include Northport Medical Center, a community hospital with 204 beds, and Fayette Medical Center, with 62 acute beds, 10 swing beds and a 122-bed skilled nursing unit.
Until about a year ago, DCH Health had five part-time physician advisors: Nunn and another retired physician, two physicians in independent practice, and a specialist in infectious disease.
“The program was light years ahead of many hospitals in growing the physician advisor practice with known physicians for support. The physician advisor role was used very aggressively for status assignment. We’ve expanded the program and added new responsibilities to the physician advisor role,” says Donna Hopkins, MS, RN, CMAC, vice president at Novia Strategies, a national healthcare consulting firm, who has been consulting with DCH Health System since late 2014.
Today, the health system has seven physician advisors who cover the three hospitals in the system from 9 a.m. to 5 p.m. weekdays and for six hours a day on weekends.
“As well as adding more physician advisors, the administration has approved adding more case managers and social workers. They see the importance of having knowledgeable staff review the admission at the time the patient presents in the emergency department or prior to elective procedures in instead of making changes later,” Nunn says.
At DCH Health System, the physician advisor role now involves far more than just patient status reviews, Hamilton says. “Not only are they advocates for case managers and a liaison between case management and the physician staff, they’re also advocating for nursing with the other medical staff,” Hamilton says.
The physician advisors still work with care managers on patient status but they also assist with documentation, writing medical necessity appeals, resource utilization, and patient throughput.
The physician advisors attend daily transition rounds with the nurses, care managers, and social workers, and participate in weekly long-stay rounds. “On daily transition rounds, the physician advisor educates the nursing staff on various medical issues and explains how certain medical problems affect the patient and long-term care. The nursing staff inform the physician assistant of the daily care and treatment of the patient, planned care for that day, and discharge plans, including discharge placement and follow-up of the patient,” Nunn says.
One of the physician advisors attends capacity rounds in the ICU and acute cardiac care unit and assists the attending physicians on moving patients to the next level of care to improve patient flow.
When any of the hospitals approach capacity, the physician advisors are alerted early in the morning to work with the attending physicians to open beds when patients can be safely discharged or moved to another level of care.
One of the physician advisors is the medical director for the clinical documentation improvement program area and works with the medical staff on providing the details the clinical documentation improvement specialists need to give an accurate picture of patients’ conditions and the care they receive.
“Clinical documentation improvement is huge. One of our physician assistants works one-to-one with physicians on documentation improvement,” Hamilton says.
Hamilton meets with the physician advisors for an hour every week to discuss any issues that have come up in the past week. All of the physician advisors meet for an hour monthly to discuss trends and issues and also attend a monthly utilization review committee meeting.
Hopkins’ team assisted DCH Health in developing score cards for the various services, including the emergency department, case management, clinical documentation improvement, medical records, and the medical staff and nursing units. At present, claims data is uploaded into a proprietary program but the ultimate goal is for the hospital system to develop its own database, Hopkins says.
The physician advisors share information on metrics and issues such as length of stay, timely discharge, transferring inpatients to an appropriate level of care, and readmission issues with the other physicians, Nunn says.
“Resource utilization is becoming a major focus as we move toward Medicare spending per beneficiary, bundled payments, and other initiatives,” Hamilton says. “The physician advisors have been a crucial component in helping us identify problematic practice patterns such as orders for unnecessary procedures or procedures that can be performed on an outpatient basis. They counsel the medical staff when there are procedures that can be done in another setting,” she says.
As the physician advisor program expanded, the hospital system brought in speakers to educate the physicians on government and private payer regulations and sent some of the physician advisors to off-site training symposia.
“We realized early on that the physician staff needed more education on the Two-Midnight Rule and the other changes that are occurring. The hospital brought in an expert physician consultant from Novia to work with the medical staff, physician advisors, and the emergency department staff on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and what it will mean to them, the Two-Midnight Rule, and observation management,” Hopkins says.
The continuing education and development program for the physician advisors is ongoing, Hamilton says.
“The physician advisors are included in every set of education we provide for the case managers. We have sessions on resource utilization, Medicare spending per beneficiary, changes in CMS and commercial payer regulations, and all of the other issues that can impact the bottom line for the hospital, and patients,” Hamilton says.
In addition, the health system has purchased memberships for all the physician advisors in the American College of Physician Advisors and the American Case Management Association and encourages them to go to educational conferences, Hamilton says.
In the beginning, the physician advisors received 50 to 60 referrals a day for patient status reviews, Nunn says. “Now referrals are down to 15 to 20 a day. The case managers realize they have the autonomy to recommend the patient status and the physicians have become knowledgeable about the requirements of CMS and commercial payers,” he says.
DCH Health System’s seven part-time physician advisors perform a variety of tasks to help ensure that the hospitals are appropriately reimbursed and that patients move smoothly through the continuum of care.
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