UR, proactive steps keep hospital days to a minimum
Discharge planning starts upon admission
By keeping close tabs on utilization and planning ahead, case managers at Harbor Medical Associates are keeping their days in the hospital for their Medicare Risk population to between 900 and 1,000 days per thousand members per month.
Skilled nursing days typically run 1,000 - 1,200 per member per month.
"With our case management model, we have unbelievable days per thousand and run below the network average. Our success is setting up expectations and goals and working with the family and the whole health care team," says Hilja Bilodeau, RN, CCM, director of case management for the Southeast Massachusetts physician practice.
The case management department also keeps close tabs on utilization, using a program Bilodeau developed on an Excel spread sheet. The program graphs out days per thousand for each physician and for the entire group and allows the case managers to keep up with utilization on a daily basis.
Physicians get a monthly report on the days per thousand in acute care, skilled nursing, and visiting nurse services days. If the figures are high one month, the case managers look at the individual cases to see if there are outliers and why.
"We constantly have our pulse on our outcomes and have utilization management meetings twice a week with all physicians to discuss all the cases. We have a program in place so that we know how many people are in the hospital, how many are seen in the emergency room, and how many are getting home care services," Bilodeau says. The case managers have seven-day coverage and call in on weekends to make sure the plans of care are being followed and if any changes are indicated.
"We also have a good relationship with other providers and our vendors, and that is one of the keys to our success," says Linda Connell, RN, a case manager for the Medicare risk population.
For instance, if a patient is accepted at a skilled nursing facility (SNF) over the weekend, the SNF knows that the Secure Horizons case managers will approve payment from the time the patient is admitted until they can review the case on Monday. The same is true with any durable medical equipment a patient may need in order to be discharged to home over the weekend.
"There is a lot of trust on both sides. The providers and vendors know that we will pay for what the patient needs over the weekend and there is no delay in getting them discharged from the acute-care hospital," Connell adds.
The case managers start discharge planning from day one, working to get patients who are in the hospital into skilled nursing facilities quickly and facilitating the admission of patients from the emergency room.
"We are very proactive about setting goals and making plans for the patients as they move along," Bilodeau says.
As soon as a patient is admitted to the hospital, the case managers do an assessment to determine what the patient’s discharge needs are likely to be. For instance, based on the patient’s condition, Connell may talk to the skilled nursing facility or start to set up home care on the day of admission.
The case managers discuss the anticipated discharge plans with the family from the first day so there won’t be any surprises. For instance, if the case manager believes that rehabilitation in a skilled nursing facility will be indicated, she suggests that the family visit the skilled nursing facility to make sure they are comfortable with it.
"We want everybody on board with the plan from day one, and if we need to adjust it later on, we do so," Connell says. If there are several skilled nursing facilities in the area, the family members get a chance to choose one, instead of feeling as though they’re being forced to go to one place at the last minute.
If a patient is scheduled for elective surgery, such as a total hip replacement, the case managers get in touch with the patient ahead of time and discuss the plan of care.
They set up home care and have the physical therapist who will be working with the patient meet with the patient and family at home to look at potential problems, such as accessible areas.
The physical therapist starts the patient education before surgery, teaching patients the exercises and bringing in equipment they will need after surgery.
If it is likely that the patient will be going to a rehabilitation setting after the surgery, the case managers arrange for the patient and family to tour the facility, meet with the staff, and decide if they are comfortable with that particular facility.
Having all the plans of care in place before the surgery occurs often results in a shorter recovery time.
"This option is much better than having it all thrown on the patients after they are discharged with pain medication," Bilodeau says.
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