Hospital nixes pathways, keeps case management
Average LOS reduced by 2 days systemwide
By using some basic case management concepts, completely doing away with others, and tailoring some to meet its specific needs, leaders at Grady Health System in Atlanta have developed a case management program that works best for the urban hospital's patients.
The model incorporates the use of guidelines and variance tracking without the use of condition-specific pathways. That's because most patients present with multi-system problems at the public hospital, making it almost impossible to determine the appropriate pathway for the patient, explains Laura W. Hurt, MHA, RN, CNNA, director of medical/surgical nursing and developer of the new program.
The new program, called the Grady Care Management Model, is helping staff manage care more efficiently and cost-effectively with the use of care managers and clinical guidelines developed with physicians. Average length of stay (LOS) across all DRGs has been reduced by an average
of two days since the plan was implemented in January 1994.
Grady Health System's model differs from traditional case management because case managers, called care managers at Grady, are able to conduct case management functions and monitor variances of an entire patient group without using critical paths. Grady operates two hospitals, seven health clinics, and a skilled-nursing facility for Fulton and DeKalb Counties.
The Grady Care Management Model incorporates the following three components:
* Guidelines used instead of pathways.
Rather than managing care on critical pathways for single, specific diagnoses, care managers use less-rigid standards of care, Hurt explains. This system enables them to better manage comorbidities.
"The demands of managed care, plus the fact that we are a county facility, by the time patients get to our hospital, [their condition] is much more than that broken hip. We find so many other problems, such as diabetes and hypertension," says Hurt.
The program allows care managers to care for the primary admission and monitor underlying problems. Diabetic patients admitted with a broken hip, for example, also would be monitored for blood glucose levels without having to worry about whether or not that is included on a pathway, says Hurt. Care managers can combine the standards of care needed for individual patients.
Tools organize CM duties
All standards of care are developed with physicians, and care managers work closely with physicians throughout patients' hospital stays.
Working with the physicians in this manner is a key component of Hurt's program because it helps the hospital's 10 care managers identify variances along the plan of care and justify additional consults to payers when needed.
* Tools help organize inpatient CM duties.
The plan calls for each medical/surgical patient care area, which average about 41 beds, to have one care manager. Consistency is ensured because the care managers all follow similar routines with the use of a standard daily schedule. (To see how case managers organize their day, see the related story, p. 12.) For example, the schedule ensures that all care managers make discharge rounds to review patient medication administration routes and ensure that all discharge planning goals have been met.
As a backup to the patient charts, a 5-by-8-foot tracking board is posted on the wall in each of the nursing units to detail daily patient needs based on the standards of care. By looking at the board, anyone can walk into that unit and see what needs to be done that day, Hurt says.
As the patient moves through each phase of care, colored squares move along the board with the patient. Blue squares are used for the admission, treatment, and discharge phases. Red squares are used for outlier phases. (To see how the system works, see the Patient Tracking Board example, below.)
Checklist used with rounds
A Care Manager Checklist For Episode of Care also was developed to assist the care managers with rounds and chart checks. The checklist includes pre-printed questions that summarize regulatory and nursing standards, which assist care managers in completing the various phases of care, explains Hurt.
The questions are divided into four categories: Admission Phase, Day 1; Treatment Phase, Day 2; Discharge Phase, Day 5 and higher; and Other (duration of stay). Parallel to the questions are three columns under the headings: yes, no, and comments. The column format allows care managers to quickly check which requirements have been fulfilled and to document specific notes regarding any of the questions.
Under Admission Phase, Day 1, for example, are the following questions:
* "Is the MD history/physical present?"
* "Does the patient require skilled nursing services and observation at the acute level of care?"
Under Discharge Phase are the following questions:
* "Are discharge medications identified, received and documented?"
* "Are there any missing, pending results of lab work and exam/consults?"
The list also gives a total picture of the expected outcomes. The document is revised as regulatory standards are added and identified, and provides a view of the full scope of practice, says Hurt.
* Variance guidelines assist in outcomes management.
Variances from the standards are recorded on a variance reporting form. This form tracks the patient's movement from the admission phase, treatment phase, and discharge phase of care, explains Hurt. As part of the program, care managers can reference the Care Management Variance Reporting Tool Guidelines, which help them clarify variances and how they should be reported.
For example, according to the guidelines, care managers can rate the severity of a variance on a scale of one to three, with one being the least severe and three being life-threatening. (To see how care managers classify variances, see the related story, p. 14.)
Monthly outcomes reported
The care managers also produce monthly outcome reports, which are essentially an analysis of the variances. Each care manager submits monthly graphs and summaries, which are presented and discussed in weekly multidisciplinary team conferences. The variance reports and corrective action plans are then submitted to the continuous quality improvement committee.
"I can tell you on any given day for a month what the variances are that we are seeing in this area," says Hurt. "For example, when we look at our practitioner/provider variances, it could be that nurses are not taking the pre-vital signs before they are taking blood. So we may decide we are going to monitor that and see if it continues to be a variance. If so, it is one that we need to correct because it means that we may have more patients having reactions, which means we pay more and they stay longer," explains Hurt.
Tracking the variances in this manner also allows for equal quality comparisons among various facilities, says Hurt.
Grady eventually may expand the case management program beyond the hospital walls "because with managed care, we are treating the whole life, not just an episode of care. Therefore, instead of getting a different nurse every time they come into the clinic, who may or may not be able to follow that patient, the patient will have a care manager who will know the patients and their habits extremely well," Hurt says.
Source: Grady Health System, Atlanta. Used with permission.
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