Tactics to Improve Utilization Management
July 1, 2022 5 minutes read
EXECUTIVE SUMMARY
The CMS waiver of Conditions of Participation for utilization management may end when the COVID-19 emergency ends. Hospitals that did not have to hold review meetings might have to return to those practices.
- Hospitals learned how to more efficiently transition patients to the least restrictive environment.
- Case management and utilization review processes need standardization. This can be helped through technology and communication.
- One way to prevent bottlenecks during a hospital surge is to help patients stand and move as quickly as possible by prioritizing physical and occupational therapy for patients who could be discharged home.
As the COVID-19 pandemic winds down, hospitals might soon find the Conditions of Participation (COP) for utilization management waiver also will end.
CMS issued the waiver during the public health emergency, which had remained in place as of mid-May.1 The waiver gave health systems the freedom to redeploy utilization review staff during pandemic surges when bedside staffing was in a crisis.
During the public health emergency, hospitals were not required to review admissions to determine if they met the hospital’s criteria for medical necessity. But this likely will change, and hospitals will need to focus on making their utilization management process more efficient.
The goal for health systems could be to ensure discharge planning puts patients in the least restrictive environment. “The pandemic expedited that work,” says Lynn Sisler, BSN, MS, ACM-RN, executive director of inpatient care management at Advocate Aurora Health in Milwaukee.
Among the biggest challenges for hospitals were both more patients and longer lengths of stay (LOS). “There was an inability to move patients to the next level of care,” Sisler explains. “That’s how the surge activity impacted hospitals — we could not turnover that bed for [new] patients.”
Case management and utilization review processes need standardization, says Rebecca Severe, MD, medical director of care management at Advocate Aurora Health.
Technology can help with communication and standardization. “We’re oftentimes presenting data to people who are not in our utilization management world, including physicians and hospital administrators,” Severe explains. “We designed a dashboard to make it easier for other people to look at it and understand.”
The dashboard contains metrics, including a case mix index, LOS, and other data. “If the case mix is high, and I’m still managing length of stay appropriately, then I’m doing a good job with our discharge plan,” Sisler explains. “If your case mix is low, and length of stay is not changing, then why is that happening? Can’t I get them discharged to a skilled nursing facility?”
The dashboard also shows the percentage of avoidable days. “We track delays in care,” Sisler says. “If LOS is very long, what are the delays being tracked that are actionable?”
Although utilization management is resource-intensive, it also can help with moving patients from inpatient beds to the next level of care quickly and efficiently.
“We at Advocate Aurora Health have not enacted the waiver; we’ve continued to have routine utilization review site meetings,” Sisler says. “We did not have to redeploy our team members who were responsible for utilization review activities. We did redeploy some of our other RN team members who were working in ambulatory settings or doing documentation improvement activities.”
“The reason we opted not to postpone or stop doing utilization management is because we thought a lot of activities were beneficial to help us move patients through the hospital efficiently, especially with high volume and capacity issues that all hospitals were having,” Severe adds.
While utilization management processes did not change, case management aspects were affected by higher volumes and more challenging dispositions. “Case managers had to be creative to move patients to the next level of care,” Severe says.
One way to prevent bottlenecks was to ensure patients stood and began moving as soon as they could. “We had them work with physical and occupational therapists as soon as possible,” Sisler says.
When patients need additional physical therapy before they can be discharged, the team discusses this in multidisciplinary rounds, Severe notes.
Hospital physical therapists cannot see every patient, every day. But they can prioritize patients, depending on where the patient will be transitioned. If the patient is waiting for a bed at a skilled nursing facility, he or she might not need as much hospital physical therapy. If the patient will be discharged home, then the physical therapist could prioritize the patient and see him or her more frequently.
“You have to prioritize the services people are providing, maximizing their mobility before they go home and prioritizing those with extra sessions,” Sisler says.
The pandemic also complicated case management and discharge planning when hospitals had to limit in-person visits by family members. “We had to learn how to do discharge planning from a remote perspective,” Sisler says. “We tried to motivate families by phone, helping them understand what the discharge plan was.”
This forced physical separation of patients and their loved ones meant case managers and other staff had to be more cognizant of caring for patients. Care managers also had to demonstrate their concern for family members through remote interactions, reassuring them the team would ensure the discharge plan was safe.
“It was hard for families to be realistic about what their loved ones needed,” Severe says. “We had to give them a realistic idea of how their loved one was doing. Often, we had to have extra conversations or care conferences that we wouldn’t have had in the past.”
Discharge planners at Advocate Aurora Health remained onsite and met with patients in person, unlike what happened at other facilities during surges. But family visits mostly were remote. “We had to [remotely] connect with family members who couldn’t be there because of COVID,” Sisler adds.
By the spring of 2022, visiting restrictions were relaxed, and families could return to the hospital, Severe notes.
The focus on remote care management work helped the teams become more efficient because they did not have to meet with teammates in person.
“On a daily basis, we have multidisciplinary roundings and meetings to make sure the whole team understands what discharge planning is for the patient,” Sisler explains. “Most of the multidisciplinary collaboration was done in the teams app, so they didn’t have to be in one area to discuss the patient.”
As the hospital’s patient flow returns to normal, more team meetings will return to in-person. “We’re not going to continue [remote meetings] wholly, but we do see some benefit in being able to connect remotely, if necessary,” Sisler says.
The meetings focus on efficiency, LOS, and moving patients through the continuum safely and efficiently. Remote options allow more participation.
“Some sites have night observation rounds,” Severe says. “I can call in and see how their rounds went today.”
The necessary LOS and other information are easy to access on the computer screen. “We have a dedicated observation unit, and we have a care management team representative, a physician advisor, and a therapist on the call,” Severe explains. “If I’m in a different hospital, I can call in and see how the rounds are going today and provide input.”
REFERENCE
- Hopfensperger K. Not so fast: Consider this before using the CMS COVID-19 utilization review waiver. HealthLeaders Media. April 24, 2020.
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