DRG Coding Advisor-Community CM program cuts hospital admissions
Is HCFA listening?
Here's a question for the federal Health Care Financing Administration: What if there were eight years' worth of data illustrating that it's cheaper to pay per visit for community nursing care for the chronically ill than to pay for periodic acute care episodes at the hospital — and that patient outcomes are better, too?
Lisa Zerull, RN, MS, has the data and eight years of firsthand experience and would like to hear HCFA's response. Meanwhile, Zerull, program director for community outreach at Valley Health System in Winchester, VA, is overseeing a program that has resulted in dramatic reductions in hospital admissions, average length of stay, emergency department (ED) visits, and critical care days for its participants.
The community nurse case management program was inspired, Zerull says, by the recurring frustration expressed by members of the patient care team. "What we heard was that we're doing a great job while patients are here, but they keep coming back." This was particularly true, she adds, of patients with congestive heart failure, chronic obstructive pulmonary disorder, and behavioral health problems.
The central issue, Zerull says, was that while the patients did not meet the criteria for home health care — that they be homebound and have a "skilled need," such as requiring a dressing change — they clearly needed post-discharge attention.
"We were seeing revolving-door patients we affectionately called 'walkie-talkies,'" she says. "They were having their hair done on Thursday, going to church on Sunday, having lunch with a friend on Tuesday. They were not homebound and had no skilled needs, but they required some follow-up in the home by a health care professional working with them toward better self-care management."
A perfect example, Zerull says, was "Edith," a 78-year-old patient who was admitted to the hospital seven times in the six-month period before she became part of the community nurse case management program. Edith had congestive heart failure, diabetes, and frequent bouts of depression. The pattern of care, Zerull explains, was that she came to the ED, was admitted to the hospital, spent several days in critical care, went on to medical telemetry, and was sent to a medical/surgical unit.
Hospital lost $98,000 on one patient
Edith's average length of stay was 12 days. Because she was a Medicare patient, there was a set DRG reimbursement rate for congestive heart failure, Zerull says. While the patient's average bill was $20,000, the average reimbursement was $6,000. "It doesn't take an economics genius to figure out that, at seven times $14,000, the hospital lost $98,000."
Researching the literature on the subject, she found a model for community nurse case management and adapted it for use at Valley Health System. "I put together a proposal and my boss said, 'Great idea, but I have no budget and no person to give you.'"
Not being inclined to take "no" for an answer, Zerull says, she came up with a different idea. "I went back to him and said, 'Would you allow me, as part of my job, to spend a half day a week to gather data [justifying the program]?"
After getting that OK, Zerull began the program, comparing utilization of services before and after. In addition to number of admissions, length of stay, ED visits, and critical care days, she looked at "perceived wellness," asking patients how they felt after the nurse visits. In all categories, the utilization of acute care services decreased dramatically, while the patients' sense of well-being and adherence to the care plan increased, she says.
On her first visit to Edith, Zerull says, she found the patient's 12 different prescription medications scattered throughout her home, some on the refrigerator, some on the stove, others in the bathroom. "I said, 'How do you take your meds?'" Zerull recalls, "and she said, 'Four times a day, I get up and decide which ones to take.'"
On the next visit, Zerull took a pill box and showed Edith how to use it, solving that problem. Although Edith, a congestive heart failure patient, was supposed to weigh herself daily to check for fluid retention, Zerull found the woman's scale pushed under a dresser and covered with dust and cobwebs. "We talked about that," she notes.
Then Zerull asked Edith a question that she says vividly illustrates the importance of the program's educational component. "I asked her, 'What if, when you get up in the morning and have chest pain, and your legs start to swell, you called the doctor's office, and maybe avoided having to go to the hospital later?'"
Zerull says the patient's response was, "Oh, I can do that?"
As is typically true with community case management, Zerull says, Edith's condition improved and her utilization of acute care services declined. "Before the program, it was seven visits to the hospital in six months. After the program, it was one visit after six months, and that was a direct admit from the physician's office."
Home care facilitates relationship
Much of the positive effect, she points out, has to do with the bond that is forged in the home between provider and patient. With average hospital stays of 4.1 days and a different nurse on each shift, the acute care setting does not provide that relational aspect, Zerull says.
"In community case management," she notes, "something happens in terms of the relationship between the health care provider and the patient that encourages compliance with the prescribed regimen of care."
That relationship, Zerull explains, will prompt a patient who's living alone, with no nearby relatives, to think, for example, "I'd better take these medicines as prescribed or that nice nurse who comes every week will be upset with me."
Valley Health System's program now has three full-time community nurse case managers who have caseloads of between 30 and 50 patients at any given time, she says. "We operate under the paradigm of spending dollars to save dollars instead of make dollars."
One of Zerull's challenges, she notes, has been getting the information systems support to determine the patient outcomes for the program. "In 1994 and 1995, I sat here with my laptop on my desk, manually extracting [utilization] information from the mainframe computer, which I had up on my PC, and entering it into the Excel spreadsheet," Zerull recalls.
Even now, she says, "every time I push the 'sum' button in Excel, I hold my breath." So far, Zerull adds, the figures continue to show dramatic improvements — ED visits, length of stay, and critical care days are all down by around 50%.
Getting past the 'fee-for-service mindset'
Despite the clear benefits of Zerull's program, it operates in an environment where fee-for-service still predominates, with managed care penetration of less than 10%. "Other than Medicare, [Valley Health] makes money by patient admissions and patient days, and in some cases, [the program] is cutting the hospital out of money."
She says community case management promotes cost avoidance, but she cautions that organizations with a chief financial officer who still has a fee-for-service mindset might resist the idea. "If managed care is driving it, there's more incentive," Zerull adds. "My greatest hope is to share my eight years of data with the feds, to say, 'It's cheaper to pay a per-visit or a per-month rate than to pay [an inpatient DRG rate] to treat the patient's illness.' If it were my grandmother, I'd rather have a really nice nurse see her once a week than have [periodic stays in the hospital]."
In the case of Valley Health, she says, the justification goes back to the health system's mission, which is to serve the community by improving the health of its members. "What better way to work with people to maintain the highest level of wellness possible than to teach them pre-crisis management — not to wait until they can't breathe?"
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