Project reviews admissions up front
Goal is to get the status right
As part of the efforts to ensure that admissions are appropriate, Covenant Health System, with headquarters in Knoxville, TN, is conducting a pilot project to test the effectiveness of having utilization managers review patients admitted to the hospital, and work with the admitting physician to decide whether the patient should be admitted or receive observation services as an outpatient.
In the pilot project, the utilization managers are reviewing the cases of Medicare patients in two hospitals in the seven-hospital system. Plans are to expand the program in 2012, according to Teresa Fugate, RN, BBA, CCM, CPHQ, vice president, case management services for the hospital system. "Our goal is to get patient status correct at the time of admission, rather than reviewing the cases 24 hours later and making changes on the back end. We are working to place people on the front end to help the admitting physicians in the decision-making process," she says.
The utilization managers staff a centrally located access center from 6 a.m. to midnight. Each morning the access center staff reviews the cases admitted from 12 midnight to 6 a.m. to make sure the patient status is correct. Having the access center review patients for medical necessity saves time for the case managers in the emergency department and on the hospital unit, giving them time to concentrate on other matters, Fugate says.
Case managers at all seven hospitals staff the emergency department during peak times. "When the emergency department case managers do not have to review patients for medical necessity, they are able to work with patients who do not meet criteria, to line up whatever support and services they may need, avoiding social admissions when the patients can't be safely discharged otherwise. We believe this initiative will save the unit case managers time because they can concentrate on care coordination and discharge planning, while the utilization managers review the records of the patients admitted overnight for medical necessity," she says.
The utilization management specialists have a clinical background and are trained in medical necessity criteria, and use of the health system's case management software. They are overseen by a RN. They are part of the case management department and attend all department meetings and training.
The access center utilization managers review patient information and admission criteria and provide advice to physicians to help them make decisions on whether the patient should be admitted, or receive observation services as an outpatient. If the patient's condition doesn't meet admission status and the admitting physician disagrees, the utilization manager can refer the case to the physician advisor for case management, and if necessary, have it reviewed by an external physician advisor company with which the hospital system contracts.
When patients are being transferred from other facilities, the utilization managers gather as much information as possible before the patient gets to the door to assist the emergency department physicians in determining if the patient meets inpatient criteria.
The access center staff facilitates and records a three-way call between the hospital's admitting physician and the referring physician, to discuss the condition of the patient. "We can't make a decision on patient status based on verbal information, but we do get enough information to start thinking about the status and whether the initial information indicates that the patient will meet medical necessity," Fugate says.
Once the patient gets to the hospital and has been seen by a physician, the access department staff reviews the additional information the emergency department physician has dictated, including the history and physical orders, and medications prescribed, and assists the attending physician on determining whether the patient meets inpatient criteria or is more appropriate for observation services.
All admissions to the two hospitals in the pilot go through the access center. "Like all other hospitals, our admissions are now being scrutinized by the Recovery Audit Contractors (RACs) and other auditors, and it's crucial that we get medical necessity and patient status right at the time the patient comes to the facility. The access center and upfront utilization management are helping us do this," Fugate says.
Source
For more information contact:
- Teresa Fugate, RN, BBA, CCM, CPHQ, Vice President, Case Management Services, Covenant Health System, Knoxville, TN. E-mail: [email protected].
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