CM model eliminates piecemeal patient care
CMs, physicians work closely at health system
Before INTEGRIS Rural Health (IRH) implemented its physician-aligned model of case management, the process was piecemeal throughout the eight-hospital system.
"There was no consistency in any hospital and no systematic approach to case management that would produce long-term benefits," says Denise Caram, MS, CPUM, CPUR, director of support services for IRH with headquarters in Oklahoma City. "The hospitals typically followed the utilization management plan with very little focus on controlling costs and lengths of stay."
Under the old model, utilization review, social work, and case management were separate entities. Some case managers were from a utilization review background; some had a master’s degree in social work, and others were RNs.
"There was not a formal process. The case managers had the clinical background but did not have the financial background to view the big picture. They didn’t realize the impact their department could have on the hospital," Caram says.
The hospital system began implementing the physician-aligned case management model in early 2000. The aims of the realignment were to ensure that patients were at an appropriate level of care, help case managers build a stronger relationship with the physicians, improve customer satisfaction, and produce better outcomes, she says.
"There was a lot of resistance initially to the new model, and in some hospitals, the turnover rate was almost 100%; but it has worked out very well. We have a very knowledgeable, comprehensive, and cohesive group now," Caram says.
Before they put the model into place, IRH staff interviewed the physicians and other hospital staff to gather information and gain support. They did an overall assessment to find out what each hospital was doing in terms of utilization and share the report with physicians and the administration, making the overall transition smoother.
"Under the old system, the physician/case manager relationships were sometimes adversarial. Now the doctors appreciate the case managers and often call on them for their help," Caram adds.
When the new system was implemented, the case managers were assigned to a group of physicians, either by physician group or physician caseload. The goal is for each case manager to see no more than 20 to 25 patients on a daily basis. Each hospital has a physician advisor to case management who conducts interdisciplinary rounds and is available to the case managers for help on difficult cases.
The case managers developed a preference card for each physician that includes information on the physician’s nursing home preference; preferred home health agencies; the best time to call; and the best way to communicate, whether by cell phone, pager, or calling the office.
"The case managers know the physicians’ patterns of visits, so most of the time they can meet with them every day, but if they miss them, they know how the physician wants the call handled," Caram adds.
The physicians were asked to develop order sets (previously called clinical pathways) for their top five DRGs. Case managers check each time a patient is admitted to see if there is an order set on the chart and follow closely to make sure everything on the order set is followed.
For instance, the hospital order set for DRG 89 (pneumonia) calls for patients admitted with pneumonia to receive their first antibiotic within two hours of admission. The case managers check to make sure it was done and, if not, question why.
"We begin to build off the process which will help provide quality of care to the patient and at the same time impact the length of stay and utilization of services. Our overall emphasis to the doctor is that we are concerned with quality and ensuring that we provide the most appropriate level of care for each patient," Caram says.
On the day of admission, the case managers start looking at what the patient needs and developing an action plan. For instance, if the patient is admitted with pneumonia, they check to make sure the X-rays and laboratory work are ordered.
They ask the physician if he or she foresees any difficulty with the patient and try to anticipate the patient’s discharge needs. For instance, if the patient came from a nursing home, they ask if the physician wants the patient readmitted there.
The case managers look carefully at the level of care patients need on the day of admission as well as the severity of illness and begin planning the discharge procedure.
Daily and weekly interdisciplinary rounds, chaired by the physician advisor to case management, have made a big impact on length of stay and use of services, Caram says. "During daily rounds, we discuss any change in patient needs and whether we foresee any complications occurring. At weekly rounds, we discuss patients with a length of stay of more than four days, complicated patients with social and family problems, and patients who have had a turn for the worse."
Each team member discusses the discipline’s treatment plan for the patient, and the entire team discusses how to better handle the case. IRH uses Interqual criteria for length of stay.
"We look at what is happening with the patients, why are they here, and what is out of the norm," Caram adds.
Each hospital has a daily census form that tells the case manager the diagnosis, the length of stay, the charges per case at the time, and what the geometric length of stay for each patient should be for that diagnosis, as long as there have been no complications. The case managers also use a balanced scorecard that shows the case mix and utilization of resources, and other data on a monthly and quarterly basis.
"We developed both of these tools to make the case managers’ job easier. They are great tools to help guide us through the process," she says.
The case managers at one hospital actually make recommendations to move patients to skilled nursing facilities or, if they are extremely ill, to the long-term care part of the hospital.
"The physicians are fine with their recommendations, and I am not sure they would have [been] in the old model. This allows case managers to be creative in movement of patients to other levels of care," Caram says.
For instance, there was one patient who no longer needed to stay in the hospital and did not qualify for Medicare but needed medical assistance and wanted to go home. Rather than keeping her in the hospital, the multidisciplinary team discussed her during weekly rounds and, with the support of her physician, decided to send her home with home health paid for by the hospital. The hospital still paid for her care, but it was much less expensive than leaving her in the hospital, Caram says. "We have been creative in doing what we can to move patients through the continuum. We’ve paid for durable medical equipment if that’s what it took to get the patient home."
Case managers in the hospital system attend quarterly education meetings during which they share patient strategies, discuss changes in Medicare and other reimbursement, and learn from each other, she says. "We did not get where we were without education. That’s why we have quarterly educational sessions to broaden our knowledge."
Over the past two years, with Caram’s encouragement, the case management staff have gone through training for Certified Professional Utilization Management (CPUM) credential. All have passed.
Before INTEGRIS Rural Health (IRH) implemented its physician-aligned model of case management, the process was piecemeal throughout the eight-hospital system.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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