Access program reduces inappropriate admissions
Nurses are located in all admissions areas
A program that places nurse case managers in all admissions areas of the hospital has helped Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, cut down on inappropriate admissions and transfers and improve patient flow.
The clinical access program was established 2½ years ago to tackle problems with medical necessity, patients being admitted without orders, patients who didn’t meet admissions criteria, and coding issues, Lesley Tilley, RN, BSN, CCM, administrator of medical services and director of medical management at the medical center told attendees at the 10th Annual Hospital Case Management Conference in Atlanta on March 14.
Now, case managers, called clinical access nurses, handle all direct admissions, all emergency department (ED) admissions, all elective surgery cases, and transfers from other facilities.
"We added a step to the admissions process. All orders are reviewed by nurses, and no one gets a bed unless the clinical access nurses approve," Tilley said.
During an average month, the nurses review approximately 2,000 orders, with about 8% of the status indicators incorrect or absent. However, the orders are reviewed prior to registration so that any issues with appropriate status can be addressed, she pointed out.
The clinical access program reports a savings to the hospital of approximately $1.3 million in charges per month, based on the number of Medicare and Medicaid charts without proper status, which are corrected prior to registration, Tilley said.
The clinical access nurses work at all access points in the hospital: the main admissions department, the admissions department in the ED, and pre-surgery testing and same-day surgery. They are in constant contact with the bed control staff.
"We didn’t want the program to be fragmented, so we located the staff at all access points," she explained.
Although they perform case management functions, the hospital chose to call the staff "clinical access nurses" because, at the time, "case manager" had a negative connotation to the physician staff.
"At the time, the case managers had the reputation with the medical staff for being chart Nazis.’ The doctors looked to us only when they had problem patients and they wanted us to help with discharge," Tilley added.
There are three full-time equivalent (FTE) positions for clinical access nurses and one FTE position for a licensed practical nurse who reviews surgical orders. The clinical access program staffs nurses seven days a week, two shifts per day from 7 a.m. to 11 p.m.
They certify the admission criteria of every patient before they get a bed, making sure that there is a diagnosis and that enough information is in the chart to ensure the patient meets Interqual criteria for admission. They make sure patients are admitted under the proper status.
House managers are in charge of admissions after 11 p.m. and coordinate all bed assignments, including transfers and trauma patients.
Here’s how the system works: Bed control receives a bed request. The clinical access nurse reviews the admission orders and discusses patient status and medical necessity issues with the physician if necessary. The nurse discusses any questionable admissions with the physician advisor. After the clinical access nurse approves the admission and the level of care, the bed coordinator assigns a bed.
"The clinical access nurses aren’t concerned about what bed a patient is assigned to. They are involved in making sure that the patient is admitted to the best level of care," Tilley said.
The clinical access nurses talk to almost every admitting physician before the patient is assigned a bed and make sure the bed status is appropriate. If there is a question about medical necessity, they turn to the physician advisor, who reviews the chart and intervenes if necessary.
The new process has ensured that patients are placed appropriately and decreased the number of patients who are transferred to the intensive care unit (ICU) because they are in the wrong level of care, she says.
If patients are frequently admitted for chronic problems, the nurses can get them admitted directly to a skilled nursing facility or a long-term acute care facility, rather than tying up hospital beds.
Our Lady of the Lake Regional Medical Center has 800 licensed beds, 30,000 admissions, 70,000 ED visits, and 18,000 surgeries a year with an average daily census of 457. As the largest tertiary care hospital in Louisiana, the hospital serves patients from a widespread rural area.
Before the program was established, patients were being admitted to the floor from the ED without orders, and it sometimes took as long as four hours before the orders were faxed to the floor. An audit of one-day stays by the hospital’s peer review organization showed the hospital wasn’t compliant.
Physicians were admitting patients inappropriately, such as admitting them to telemetry beds when an ICU bed wasn’t available, resulting in transfers of patients to the ICU.
Referring hospitals were sending patients to Our Lady of the Lake because they had been in their facility a long time and were running out of benefits but had nowhere to go.
"That really affected our patient flow because we had inappropriate patients in the beds and we weren’t able to discharge them," she added.
Tilley had been director of medical management for just six months when the hospital decided to tackle patient access. "My boss was 100% behind it, but it was still overwhelming. The fact that our doctors didn’t like working with case managers at the time made it more of a challenge," she said.
Before beginning the project, Tilley and her team looked at patient data to determine when and where the services were most needed. They used data from an outside audit and did their own audit, determining which physicians were admitting patients, where they were being admitted from, and which days of the week and times of day had the heaviest admissions. They looked into how housekeeping issues affect admissions, checking for any times of day that there were backlogs in bed availability.
They studied the bed coordination and bed assignment process and assessed the educational needs of the medical staff and employees.
Goals for the program included:
• enhancing the quality of care delivery;
• creating a patient- and physician-friendly environment for access;
• controlling resource utilization;
• establishing admissions criteria;
• verifying proper status indicators;
• meeting corporate compliance requirements.
Tilley and her staff developed the program with the help of their physician advisor, who brought the plan to the medical executive committee. "He told doctors why it was important to get their support for this new program. One goal of the program is to enhance the quality of care delivery by ensuring that patients are admitted with orders and eliminating waits for care. This was a strong selling point with the hospital’s physicians," she added.
The program is staffed with experienced nurses with knowledge of Interqual criteria, familiarity with community resources — such as home health and durable medical equipment providers — who understand Centers for Medicare & Medicaid guidelines and other regulations and are knowledgeable about managed care contract structure.
The nurses began immediately to establish a positive relationship with the physicians.
"We wanted these nurses to be the frontline ambassadors for patients and physicians, someone the patients can talk to while they are waiting for admission and someone the physicians can use as a resource," Tilley explained.
The team received approval from the hospital’s compliance office and senior manager and began to educate all employees who are involved in any way in the admissions process. That included nurses, the ED staff, the admissions staff, the case management team, the medical staff, and the house managers. "The education process took longer than coming up with the idea and designing the program. We changed the way things work, which is sort of like turning a ship around," she said.
The department tracks the number of charts reviewed daily, number of inappropriate status indicators by physician, number of inappropriate admissions, and number of inappropriate transfers. The physician advisor discusses inappropriate admissions and status indicators with individual physicians. Tilley compiles the percentage of total admissions reviewed, charges or costs associated with charts without appropriate status, and reports monthly to the CEO, the CFO, and the COO.
"We can look at Medicaid and Medicare payments and show how making sure a patient is appropriately admitted saves revenue," she pointed out.
A program that places nurse case managers in all admissions areas of the hospital has helped Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, cut down on inappropriate admissions and transfers and improve patient flow.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content