UM can help prevent unnecessary admissions
Capitation success is at stake
By Patrice Spath, ARTConsultant in Health Care Quality and Resource Management
Forest Grove, OR
Once a hospital enters into a joint capitated payment agreement with primary care physicians, the incentives for cost containment change. Short hospital stays are no longer utilization management’s (UM) primary objective. The goal becomes reduction of unnecessary or preventable hospitalizations. Hospitals are positioning themselves for this new perspective by implementing outpatient case management programs for elderly patients, those with chronic diseases, and other "revolving door" patients. These programs include comprehensive discharge planning, home visits by nurse practitioners and other caregivers, and regular phone calls to ensure patients’ compliance with follow-up instructions.
Even with outpatient case management, hospital utilization management will continue to be an important element in a hospital’s strategic managed care initiative. Reviews of admission and appropriateness of continued stay must be done for those patients who require hospitalization. Prevention of unnecessarily long hospital stays remains a priority for patients enrolled in a capitated managed care health plan.
In addition to their traditional review activities, however, UM staff can be instrumental in identifying preventable hospitalizations. Working closely with the managed care program partners — primary care physicians, home health agencies, outpatient case managers — the UM staff should establish a formal monitoring program to identify inpatient admissions that might represent inadequacies in outpatient management practices. These cases can be discussed at the UM committee meetings held jointly by the hospital and the participating physician clinic(s) and other caregivers.
Use your clinical/financial information system to identify patients admitted to the hospital with ambulatory-sensitive conditions. These are conditions for which the probability of hospitalization could have been greatly reduced by adequate primary care. To select these conditions, researchers conducted a literature review and obtained clinical guidance from practicing physicians. (A list of these conditions and their corresponding ICD-9-CM codes is inserted in this issue.)
Cases such as these should be analyzed to identify the circumstances surrounding the admission. Ideally, this analysis is undertaken by the primary care physicians who are partners with the hospital in the managed care plan. If these physicians are unable or unwilling to review cases, the task could be delegated to the hospital’s UM committee. To determine whether or not the hospitalization could have been prevented and how it could have been prevented will require the committee’s review of clinic and other ambulatory care records.
Some patient hospitalizations are unavoidable due to the natural course of their chronic disease. However, many might have been prevented through improvements in outpatient services. For example, the individual may not have had adequate access to primary care services, which resulted in an exacerbation of his or her condition. An individual’s access to adequate primary care services can be influenced by:
• transportation to facilities;
• availability of child care;
• clinic hours of operation;
• linguistic barriers;
• patients’ health care beliefs;
• patients’ living conditions or environmental concerns.
The committee also should look for system problems that affect the incidence of preventable hospitalizations, such as unavailable community resources, inadequate quality of care, and integrated delivery system inefficiencies. (The committee can use the report format shown in the insert to document review findings and suggestions for improving the system of care.)
Reducing preventable hospitalizations will require implementation of several different action plans. To effect changes in patients’ lifestyles and health behaviors, patients must have interaction with the primary care system; in other words, access problems must be overcome. It may be necessary to offer patients free transportation services, expanded clinic hours, increased urgent care services, telemanagement services, and so on.
If quality of care is found to be a problem, the committee may need to develop clinical practice guidelines and disseminate them to caregivers, or mandate continuing education requirements. Shown in the sample report in the insert are examples of the types of problems that might be identified when reviewing cases of potentially preventable hospitalizations and the possible causes of these problems.
Whether these case-review activities are performed by a committee at the clinic level or one sponsored by the hospital, it is important to document the process. (See the insert for an individual case review form.) Periodically, the findings should be aggregated and reported to the committee to help identify recurring system problems that have yet to be resolved.
UM will continue to be an important ingredient of a provider’s capitation strategy. However, the utilization manager’s responsibilities should expand to include an analysis of preventable hospitalizations. UM activities should include a comprehensive review process and close communication with ambulatory care providers to minimize unnecessary use of costly hospital resources.
(Editor’s note: See January’s Hospital Peer Review column on "UM can’t be one-size-fits-all: Managed care arena requires special skills," p. 16. Next month: How UM departments may function as claims analysts in capitated payment systems.)
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