Nurse screens orders before admission occurs
Patient, health system said to benefit
Screening admissions in advance for medical necessity is part of the routine at University Health System in San Antonio, thanks to an innovative utilization management program that appears to benefit both patient and hospital.
The effort began almost two years ago, when admissions and the emergency center (EC) were put under the supervision of Betty Goularte, RN, BSN, CPHQ, director of utilization management, admissions, and the EC.
"I began to see that, being a teaching and county hospital, we had a lot of patients that seemed to be walking through the front door to be admitted that didn’t need to be admitted," she explains. "The admitting staff knew to call the physician’s office if an admitting order was incomplete but were never really trained in conferring with the physician. No one ever stopped to say, Is this really an appropriate admission?’"
In other cases, physicians might not know there’s an alternative to inpatient admission, or they may not have thought about it at all, she notes. "Their idea is just to take care of the patient."
With stringent rules determining medical necessity and more procedures relegated to an outpatient setting, such an approach is not the best one for the patient or hospital, Goularte suggests. "A lot of times physicians feel they want to get the patient in and treated right now. That doesn’t always work in the patient’s best interest. When the physicians understand that [with non-urgent procedures] waiting a few days would help get [financial] coverage for the patient, they are usually very good at working with us." (See related story, above.)
Her solution was to formalize what had been an informal arrangement with utilization management (UM), she says. "We had been doing some liaison [work] with admitting, but it was cursory, just when we were called to send a nurse over to look at an admitting order. I decided to go for a full-court press."
A UM nurse was moved into the admissions department, where she works with the entire staff, particularly those employees overseeing admitting orders from physicians. The department uses admitting criteria that are part of published nursing guidelines to help determine the appropriateness of an admission.
Avoid red flag’ situations
The idea was to be proactive instead of having UM pick things up retrospectively, when the patient was already in a hospital bed. It’s considered a red flag, for example, when an order says the patient is going to have surgery, but there are a lot of diagnostic procedures to be done first, Goularte explains. "The surgery might or might not be done."
The UM nurse also would question an order for a patient to be admitted for incision and drainage. "That’s primarily an outpatient procedure, de -pend ing on the condition of the patient. We have to know that outpatient therapy has failed. If it didn’t work, that patient will get in the door."
Gall bladder removal is another procedure that was done in a hospital for years but now can be done laparoscopically on an outpatient basis, she notes. "Unless you know this, you don’t know to call the physician. That’s why it’s easier to teach a nurse [to screen admitting orders] than an admitting person."
Goularte’s own practice of calling physicians when she hears about questionable admissions predates her position as admissions department director, she adds. "The trail goes back several years. On the retrospective side, I was seeing Medicaid and Medicare patients getting in here who did not meet medical necessity."
Over the years, the medical necessity criteria have been expanded to include more and more patients. This past focus on medical necessity is one reason physicians are as cooperative as they are with the admission screening, Goularte suggests.
In rare instances, a physician might become defensive when an order is questioned, but it helps that a trained nurse is calling, she says. "And we don’t just start by saying this is an inappropriate admission. We ask if there’s any reason the physician is doing this as an inpatient rather than an outpatient procedure. Then we say, Can we do it another way? I will help arrange it.’"
A UM nurse will never deny an admission, Goularte emphasizes, but she does have a backup if physicians refuse to discuss an admitting order. "There is a utilization review physician who is a consultant to me, and she can deny an admission. If I have someone who will not talk to me or the nurses, this person is called. She contracts with the hospital."
In most cases, adds Sandy Taylor, RN, the admission nurse coordinator, physicians are pleased when they understand that modifying an order would benefit the patient and facilitate appropriate billing for the hospital. "They want to take care of the patient," she says. "If we can handle the details, that’s fine with them."
Some 10% of admitting orders are discussed with the physician, with the suggestion that the patient be handled in a different way, Taylor estimates.
"It’s hard to get our hands around the money saved," Goularte says, "but we know that money is saved. We’re trying to find a way to quantify it."
Effective education a must
The measure of the program’s effectiveness may not come in numbers, however, but in the education it provides for physicians, Taylor suggests. "It’s making them more aware that these issues need to be addressed, that they affect the patient."
If a Medicare patient is incorrectly put in "admit" rather than "observation" status, the patient will be responsible for paying the deductible for an inpatient stay, she points out. With commercial accounts, the admission request form shows that authorization was for an outpatient or observation patient, not for an inpatient stay.
"We’re a teaching facility, and many residents and some attending physicians are not familiar with the details of payers," Taylor says. "Sometimes the clinic obtains the proper authorization, but when the order for admission is written, that order may need to be clarified."
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