CM system cuts denied days by setting priorities
Daily dashboard’ identifies barriers to discharge
By modifying its automated case management system to identify patients with barriers to discharge, enabling the clinical staff to set priorities, Good Samaritan Hospital in Baltimore was able to decrease the percentage of denied days by more than 50% in just six months.
From June 2004, when the system was implemented, to December 2004, the hospital experienced a 26.6% reduction in the length of stay (LOS) of patients not meeting admissions criteria and a 30.6% reduction in the LOS of patients not meeting continued stay criteria.
The time it took to get patients discharged after it has been determined they don’t meet criteria dropped from 1.87 days to less than a day.
Good Samaritan Hospital, the fastest growing hospital in Maryland, has seen unprecedented growth over the past two years, with a 16% increase in admissions and a 25% growth in emergency department (ED) visits in 2004.
"Throughput is the No. 1 challenge, says Steve Blau, LCSW-C, director of case management for the 276-bed hospital.
When hospital administrators began looking at ways to expedite discharges to free up inpatient beds, they found that a lack of priorities was contributing to delayed discharges.
The hospital implemented a case management system from Cary, NC-based Canopy Systems in June 2004 and customized it to create what Blau calls "a daily dashboard" that identifies patient priorities throughout the hospital and alerts the appropriate clinicians as to what they need to do to move each patient through the continuum.
"Our original goal was to implement a system that would streamline case management processes and help us to improve the coordination and delivery of care. We also wanted to develop a visual dashboard of existing priorities for taking care of patients. I never realized how far-reaching this tool would go and what a thirst and desire there is among hospital staff for a work-flow system that would support better communication of priorities," Blau notes.
The dashboard identifies patients who do not meet criteria; barriers to discharge, such as tests pending; discharge dates; and estimated times of discharge. For instance, when case managers identify patients who do not meet admission criteria and those who no longer meet continued stay requirements, they flag the patients with red or blue alerts, designated by a red or blue bell, for immediate review. The system generates a list of patients who don’t meet criteria. The report is sent via e-mail through the case management system to the medical staff leaders, hospital managers, and case managers.
"The alerts were not originally intended for flagging inappropriate admissions or avoidable days. We tailored them for this purpose because we recognized the power of having our clinical staff know at one glance who they should be focusing on," Blau says.
The hospital uses InterQual criteria to establish the level of care and Milliman USA care guidelines to determine the treatment course.
"When we identify patients who are nonacute, the question is, who do you tell so it’s not just the case managers who are managing them? We wanted to go beyond the people standing over the case manager’s shoulder asking who is ready for discharge. We wanted to make this information visible and easily accessible," he adds.
As case managers evaluate their patients each day, they focus on the one or two most important and pressing things that must happen with the patient that day. They input the information into the software system where it is accessible to all hospital staff with links to the case management system.
For instance, the patient needs a laboratory evaluation, cardiology consult, and physical therapy evaluation. The case manager puts it in the system and identifies the biggest issue that needs to be resolved immediately. The case managers’ input is dynamic and changes all during the day.
The views are modified for each department to include only the information the department needs. For instance, the physical therapy department sees all patients scheduled for discharge pending physical therapy evaluation. The social worker checks the system for any discharges pending home care setup, nursing home availability, or durable medical equipment setup. The cardiology department looks for discharges pending a cardiology consult, an echocardiogram, or an EKG. The nurse looks for discharge pending patient education, family education, or discharge summary.
The software has a drop-down screen, listing options case managers can choose. If a case manager is concerned about the patient meeting criteria, he or she will flag the patient in the system.
"Every day, people need to know where to start. Before we had this system, all the case managers would call down to the ancillary department every day and say their patients are a priority. The real value of the system and how we are using it is flagging patients to show what their barriers and issues are. When they know what the issues and barriers to discharge are, people in the ancillary departments can be totally self-organized and adjust their scheduling," Blau continues.
Any time the case manager flags a patient, appropriate information pops up on the desktop of the clinical department that needs to know about it. For instance, when a case manager certifies that a patient isn’t acute, it pops up on the desktops of the chief hospitalist, the chief of medicine, the chief of surgery, the physician advisor, and all nurse managers.
At Good Samaritan, every unit is staffed by two case managers and a social worker. One case manager handles utilization review while the other is in charge of coordination of care. The social worker complements the team.
Every patient admitted to Good Samaritan is assigned a working DRG and an anticipated discharge date. The goal is to get every patient into the system as early as possible. "Everybody on the team has an independent workstation. I can’t imagine the team working to its optimal abilities without it," Blau says.
The case manager who handles coordination of care on each floor is the team leader. When case managers come to work, they get a work list from the Canopy system, listing all the new admissions. Instead of spending an hour in the office getting ready for the day, the case managers access their work list and take their wireless laptops to the floor.
The case management staff has a 15-minute daily huddle each morning before they start the day to review what’s going on.
"We talk about what our priorities are, who needs help, and any barriers to discharge. It’s a wonderful vehicle for getting real-time issues resolved without waiting for a weekly staff meeting," Blau says. He regularly attends rounds with the ancillary staff and nurse manager. That gives him the opportunity to show them how useful the information in the case management system can be to them.
Tracking changing needs
Each day, the case management staff break out expected discharge times into four-hour windows and give a report to the charge nurse. "It helps with the shift change and helps the emergency department [ED] and bed control know when beds will be freed up," Blau notes. At 11 a.m., the case managers hand off a report to the charge nurses citing the barriers to discharge for patients, estimated discharge times, the discharge plan, and a list of people whose conditions are not acute.
A continuous report, in real time, goes to bed control throughout the day, listing who is being discharged and at what time. "No longer do people look over the case managers’ shoulders and ask who is ready for discharge," he says.
Before the new system was implemented, the case management staff organized times and performed day-before-discharge planning.
"Discharge times are only one piece of the pie. On a well-organized unit, you can do day-before-discharge planning, but some patients are unpredictable. The case manager on the medical units encounters this volatility every day, particularly since those units are tightly run and the average length of stay is only three to four days," Blau says.
Patients’ needs can change throughout the day, and case managers need a way to track that, he says. For instance, the interdisciplinary team could create a plan of care for a patient during morning rounds, but two hours later, test results show that his blood urea nitrogen level is elevated and the treatment plan has to be changed. "Things are so dynamic and change so quickly that you can’t rely on the plan of care. Care plans are good for the long term, but operationally we needed a way to manage and understand priorities concurrently," Blau explains.
One of the challenges Blau and his team have encountered in moving patients through the continuum is that the case managers are geographically based. "At any point on any given day, patients can be transferred from one unit to another. One of the challenges we face is losing time when the patients are transferred," he says.
The team faced similar challenges with large group practices who admit numerous patients and have a "doc of the day" making rounds and scenarios where nurses work staggered schedules.
"On any given day, we may have a new nurse taking care of patients and a covering attending, neither of whom have a clear idea of what has to happen with the patient and what the barriers are. Case management provides continuity to people who are new to the case," Blau says.
At Good Samaritan, 70% of admissions come from the ED. The hospital has created an Emergency Progressive Care (EPC) center where patients can get a nursing assessment and diagnostic testing while they still are waiting for a medical/surgical bed. "By the time they hit they floor, the treatment is started. It gives the case managers an opportunity to get a jump-start on what we have to do after admission," he says.
The case managers in the EPC start admissions assessments. If a patient is going to need studies by ancillary departments, the case manager has them already in the works before the patient gets to the unit. In the past, the department tracked avoidable days and sent out monthly reports to department leaders and the medical staff chairs.
"They said the information wasn’t timely enough, and they wanted it weekly. Now it’s at our fingertips, and we can run a report every day. Now I do it twice a day. What I am doing is to identify avoidable days concurrently so we can make sure they don’t happen," Blau says.
The list includes only two to five avoidable days each day, but over a month, it all added up.
For instance, if a patient is scheduled for an MRI but a backlog is scheduled for the morning, Blau can contact the manager who is responsible for the backlog in real time and get the problem corrected. "We’re still doing trending, but we’re also tracking it daily as a troubleshooting technique. The trending is at a higher level so we can look at process improvement as an organization," he adds.
When Blau meets with physicians to discuss an avoidable day, he can print the documentation he needs to show exactly what happened.
"It’s an irrefutable situation, and I don’t have to say anything more," he says.
The hospital has an appeals coordinator who works with case managers to help them concurrently identify cases that are being denied.
The hospital hired a physician advisor who is an expert in admission and continued stay criteria and is well versed in InterQual and Milliman guidelines.
"We are communicating to all our nurse leaders, bed control, and physician leaders every day, patients who are in-house who don’t meet criteria. When case managers talk to physicians about patients who don’t meet criteria, they’re not always speaking the same language. We’ve invested a great deal of time in educating our nurse case managers so they have the skills to explain why a patient doesn’t meet criteria in a way that the physicians understand," Blau says.
Before the system was implemented, case management staff brainstormed to identify all the information that other members of the clinical staff ask them every day and looked at ways they could quickly get the information out to them. "We found out that people want to know who is being discharged, when are they going, what are the barriers to discharge, what are the patients’ needs, and who shouldn’t be here," he notes.
Case managers get those questions every day from the administrator on call, the nursing supervisor, the chief of medicine, the hospitalists, the bed control department, the charge nurse, and the nurse managers.
"I’d have to stand in line to talk to one of my case managers. We were under a great deal of pressure to move people through," he says.
The case managers started making long hand-written lists but had to change the list every time someone looked at a patient. Blau wanted to make all the information that affects patient throughput visible so multiple parties know at the same time where the problems are and who is responsible.
"We want to make sure that case managers aren’t the only ones tracking barriers to moving the patient through the system," he says.
The team had meetings with the physicians who admit 90% of the patients and with the ancillary departments to educate them on what to expect.
[For more information, contact:
- Steve Blau, LCSW-C, Director of Case Manage-ment, Good Samaritan Hospital, Baltimore. E-mail: [email protected].]
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