NC hospital successfully integrates care
Medicare prepared them for managed care
In 1991, well before managed care hit their market, administrators at Haywood (NC) Regional Medical Center began the process of centralizing quality under the authority of the case management department. Two years later, case managers at Haywood were responsible not only for managing patients but also for discharge planning, utilization review, patient education, risk management, and quality improvement. Now, they're taking on outpatient case management as well.
The key to making this centralized approach work is identifying high-risk populations early and managing those patients aggressively, says Teresa Fugate, RN, director of case management at Haywood. Although case managers perform utilization review for all patients who enter the hospital, they manage only those who fit into high-risk categories, she says.
"What we've done is develop physician protocols, pathways, patient education materials, and now community case management follow-up programs based on our high-risk patients," she says. High-risk populations at Haywood, which has a high percentage of Medicare patients, include congestive heart failure, CVA, total hip and knee replacement, and pneumonia patients. "From there we do very specific things with those patients, including their education."
They did all this despite the fact that even now, managed care penetration in Haywood's market remains relatively low, Fugate says. "A consultant recently came in here and said that he couldn't believe we had a program here with this level of penetration, but that we were definitely set up for managed care," she says. She notes that managed care has hit nearby markets and that Haywood is one of several North Carolina hospitals gearing up for their turn.
One reason Haywood encountered little resistance to the idea of integrating quality under case management is that the hospital's patient population historically has been between 50% and 60% Medicare. "And if you look at that, then you've had to manage your money with very limited resources," Fugate says. "So managed care is not going to be that big of a problem for us considering how we've managed before."
Even so, Haywood's existing case managers had an adjustment to make when utilization review and discharge planning were brought on board, Fugate says. Although the discharge planners adjusted well, utilization reviewers had a more difficult time dealing with their additional responsibilities. "When people don't adjust well, it can hold your program up," Fugate says.
Because of turnover in the department, however, Fugate has been able to hire case managers who have been aware up front of the scope of their case management responsibilities. She says she looks particularly for case managers with a strong clinical background and patient focus who also have been motivated to stay abreast of changes in health care and their role in it. "I look for someone who has kept up with her career professionally and considered moving out in other directions - someone who understands managed care and is self-directed," Fugate says. "In other words, they learned this on their own."
Fugate adds that she didn't necessarily favor applicants who had already been case managers. More important to her was to get people who could see "the bigger picture: How financial overutilization could ruin both the quality of care for patients and the future of a health care facility."
While an understanding of the financial aspects of health care is crucial, Fugate says, the bottom line remains patient care. "If they're coordinating services and making them more timely and efficient, then they're doing that for the patient," she says. was what I was looking for: that knowledge of patient perceptions; someone who had worked in multiple areas, such as the surgery floor or intensive care unit and had a good clinical background. Because I can teach the financials, but I can't teach the clinical side. They have to be clinically sound to begin with in order to learn the financial end and understand how those two work together."
Haywood, a 200-bed facility, currently has five case managers, with two based in the medical center's preoperative clinic. One serves as coordinator of the clinic while the other supervises patient resource services. "So we actually get started with a patient for utilization in the pre-op clinic," Fugate says. "The process starts right there before they ever come into the facility for an elective surgery." In the clinic, case managers check patients' insurance and assess what patients' needs will be upon discharge. For non-elective surgery patients and other emergency cases, such services start upon admission to the hospital. "We also are moving into covering for case management in the emergency department, outpatient surgery, and our urgent care center," she says.
Despite the progressive atmosphere at Haywood, case managers have faced mixed reactions from physicians in seeking to implement quality initiatives. The main factor was the low level of managed care penetration. Even so, work by the medical center's performance improvement chairperson and key members of the medical staff have helped to win some physicians over. "Our chief of the medical staff is very much future-oriented," Fugate says. "He's a real champion in getting the medical staff the education that they're going to need and bringing them around."
Another factor that has encouraged physician buy-in at Haywood has been the success of the facility's pathway program. In particular, the pneumonia pathway helped to cut pneumonia mortality from 11.6% in 1994 to about 6% by 1996, while average length of stay declined from 8.6 days to seven. "The pneumonia pathway has gotten such good results that they really couldn't deny the numbers or the information," Fugate says. "So all of a sudden, they're wanting to be involved, and actually physicians now are driving the processes. It's happened so suddenly that it's hard to keep up."
For more information, contact Teresa Fugate, RN, Haywood (NC) Regional Medical Center. Telephone: (704) 452-8748.
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