CM program helps make hospital profitable
CMs assigned to physician groups, not units
Last year, facing serious operating losses to the tune of $2.6 million, Bradford (PA) Regional Medical Center, a 150-bed rural facility, launched a bold initiative to boost quality of care and patient satisfaction while reducing resource utilization. The resulting clinical resource management program, staffed by six case managers, has achieved dramatic results after only six months in operation:
· The average length of stay (LOS) for all Medicare cases (excluding psych) for July 1997 through June 1998 was 5.8, compared with 6.3 for the same period during the previous year.
· The average LOS for all Medicare cases (including psych) dropped from 6.8 last year to 6.4.
· The average LOS for all payers dropped from 5.6 in 1997 to 5.4 during the same period in 1998. (See chart, p. 176.)
Ashifa Bhayani, director of patient quality management at the medical center, is quick to stress that LOS doesn't tell the whole story. She notes that resource consumption often can be compressed into the first few days of a hospitalization. But, she adds, the less time patients spend in acute care, the lower the odds that they will develop nosocomial infections or other complications.
If hospitalwide LOS data aren't enough to grab physicians' attention, the information Bhayani tracks about their individual performances is. One high-admit internist, for example, saw his average LOS drop from 6.2 in the last fiscal year to 5.4 this fiscal year. His average cost per Medicare case dropped by $1,093 over the same span. Whereas in the prior year, the hospital lost a substantial amount of money ($2.6 million), it now registers a slight gain in certain patient populations. In fact, each of the hospital's 11 targeted physicians have seen their average LOS and resource use per case drop during the same period. (See chart, p. 176.)
"We threaded lightly on resource utilization in the first few months," Bhayani says. "First of all, we needed to engage the doctors so they could trust that their case managers were people they could have a good relationship with. I wanted to let it evolve, rather than start with, 'We're here to influence your practice style.'"
Ultimately, influencing practice style is precisely what the clinical resource management program is all about. Just as the case manager attempts to break down the obstacles to efficient patient care (such as delayed lab results), she also tries to break through practice patterns born in a fee-for-service era.
Indications are that it's already happening at Bradford. One skeptical internist, for example, recently called on his case manager to find out why the emergency department had ordered so many tests for one of his patients. In total, clinical resource management initiatives to reduce cost per case, length of stay, and variation in practice have produced $430,944 in savings, Bhayani says.
"[Last year,] we faced a combination of budgetary moves by the state of Pennsylvania, decrease of payments by Medicare, and increased penetration of managed care," she says. "We decided to look at reducing operating expenses so that we could remain a stable and reliable organization in conducting our mission and vision - namely, to be here for the community."
With help from McFaul & Lyons, a Trenton, NJ-based consulting firm, Bradford began a comprehensive work redesign program. Staff were grouped into teams to tackle specific work areas. Bhayani, who directed the admitting, medical records, and utilization review departments, was selected to head the utilization review team.
The team set about developing a process that would help Bradford maintain excellent clinical outcomes for its patients while eliminating non-value-added interventions. Its emphasis would be on the appropriate use of hospital resources and the coordination of inpatient care with self-care and community resources, the team decided. What emerged was case management.
As either RNs or BSNs, Bradford's case managers get involved in preadmission management, admission management, continued stay management (including assessing the appropriateness of interventions), patient and family support, discharge planning, and performance outcome evaluations such as tracking potentially avoidable days.
"They're managers without portfolios," says Stefani Daniels, a senior consultant with McFaul & Lyons, who helped design the program. "They don't direct or supervise anyone, nor do they practice clinical care. Their responsibilities are too broad and their accountability too great."
Instead, Daniels says, they form links among patient, doctor, family, payer, and non-hospital providers to ensure the patient receives the best care with the most appropriate resources and a minimum of wasted time.
Although Bradford's patient mix is just 7% managed care, 45% of its patients are Medicare and 22% medical assistance, or Medicaid, Bhayani explains. The hospital was consistently losing money on its heaviest DRGs, and with managed care about to grab an estimated 25% of its federal population, Bradford knew it needed to take action. But were the doctors ready for clinical resource management?
"If you have the time and money to waste, that's fine with us," one internist told Bhayani upon hearing of the program.
"Physicians want assistance," Daniels says. "They want practical advice, and they want to be able to withstand the scrutiny of third-party payers. But they don't want someone else to control their practice."
To help win over physicians, Bhayani assigned each case manager to a team of physicians instead of a unit. At a small hospital, teaming case managers with physicians can quickly build trust and rapport, she says. It's also less confusing for the physicians as they move from unit to unit visiting inpatients.
As the case management program continues to develop, she hopes to extend it beyond acute care into physician's offices and Bradford's nursing home. "I want to reduce rehospitalization for congestive heart failure to zero. If we can do that, those patients will have a better quality of life, and they won't have to come back to the ED some day with a major problem."
For more information, contact Stefani Daniels, senior management consultant, The McFaul & Lyons Group, 306 Horizon Center, Trenton, NJ 08691. Telephone: (954) 941-6505.
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