PHOENIX: The Hospital Case Management Company will be hosting a hospitality get-together for hospital case managers and subscribers to our newsletter, CRM UPDATE, who will be attending CMSA's national conference in Orlando, FL.

Stefani Daniels, Marianne Ramey, BK Kizziar and Barbara Fair will be delighted to meet with old friends and new colleagues and invites everyone with an interest in hospital case management to join them.

Wednesday, June 9, Coronado Room P, from 6 pm to 8 pm

From time to time, we remind our readers that the hospital case manager's primary obligation is patient advocacy. Advocacy is manifested in many ways throughout the progression-of-care that is the focus of outcome models.  From advocating during the access process to make sure that the high-risk hospital venue is the best place for a patient to receive the care she or he needs to querying the physician on his practice decision to use an expensive antibiotic when evidence shows that a less expensive one is just as effective, examples of patient advocacy abound.  



At another level however, adovacy is the face of the hosptial.  In an outcome model, case managers are visible and present.  They are not combing through charts or scanning electronic screens to find information.  They get their information from rounding with their physician partners, from reaching out to the nursing staff, from interacting with ancillary department providers all of whom affect progression-of-care.  And often, because medical coverage may rotate and nurses change shifts, the case manager becomes the single consistent resource for the patient and adds the personal touch that distinguishes one hospital from another. 



We are reminded of a recent story from Cabell Huntington Hospital when a physician came down to the office to offer his personal thanks to his case manager for extending herself beyond expectations to help his patient.   "This was a veteran who landed on Normandy Beach," explained the doctor, "and I'm delighted that he received the care and attention that he rightfully deserved." 



"Care and attention" speaks volumes to the obligations we all have to our patients. Case managers translate those words every day into pro-active advocacy activities.    

You've certainly heard the adage "You get what you pay for."  It reflects the commonly held notion that by investing wisely in a service or product, you should reap benefits equal to or greater than the initial investment.  The converse is true as well.  If we buy an inexpensive product, we are disappointed but not surprised when it fails.  We might refer to this purchasing equation as a value proposition.  The perfect balance to this proposition is to invest just enough to feel satisfied with what we receive.  We are excited when we feel that the value of a purchase exceeds its price.  It applies to everything we purchase in life, and it applies to case management staffing as well. 



When visiting with clients, we are always asked, "Are we staffing appropriately?"  Answering this question is never easy since there are so many variables to consider:  What is the purpose of the hospital's case management program?  How is the value of the case management program measured?  What standards of practice are promulgated?  The questions and variables go on-and-on and in the end, there is no one best answer.   There are, however, key staffing issues that every hospital case management program should consider when evaluating the effectiveness of it's resource availability.

  1.  What are legacy activities versus required activities.

  2.  What skill mix is necessary to perform required activities.

  3.  Who are the Case Manager's customers and how are they reached.

  4.  What are the expected measurable outcomes with which the program will be evaluated.

  5.  What information is needed to Reward and recognition programs.

Answer these questions first, and answer them from the big picture perspective of a 21st century outcome model, and you will be on your way to evaluate the appropriateness of your staffing resources.   

Quick......shout out your hospital's readmission rate for heart failure patients!  Don't know?  OK, instead, shout out your clinical denial rate!  Oh my, you don't know that either?  One last try...can you identify the average length of stay in your critical care units? 

Don't be embarrassed if you don't know the answers to these questions:  Either the information is not tracked and therefore not available, or it is a symptom of legacy thinking that the people expected to influence these numbers don't really need this basic information to monitor their effect.    



The high cost of poor data is evident all around the hospital and while hospital execs are scrambling to improve the situation, it's been slow in coming.   Data access and data quality are especially important because the organization's data base feeds so many other departments.  For example, based on the totally unscientific surveys we conduct at client hospitals, case managers report upwards of 60% error rate in registration information!  Given that so many other hospital activities rely on registration data, an error rate that high, or even half that number, is inexcusable.  Just consider how many other departments use that data including the medical staff.  The result is waste and unnecessary costs.



Accurate, accessible and actionable data must be top priority for hospital execs and every hospital case management leader should make their need known. As hospital case management programs continue to evolve, the case managers' role as an influencer, advisor, and advocate will expand.  There must be an organizational wide commitment to proactively and continually correct, consolidate, and disseminate objective information to benefit overall organizational efficiency.  Data quality and routine data availability cannot be sustained with a one-time fix.  It is a discipline that must become routine.   

The face of hospital case management (HCM) and the role of the case manager continue to evolve.  Programs designed during the re-engineering craze of the 1990s are giving way to 21st century advocacy concepts to promote value, outcomes, and professional practice.  For the most part, discharge planning and utilization review functions are still aligned under the hospital's case management umbrella, but it is progression-of-care and outcome achievement that have taken center stage over the past ten years.  



Progression-of-care (PoC) is often described as the basic building blocks of a case manager's scope of practice.  Within that scope are the components of CMSA's core processes.  Using the three primary components of an acute episode of care - access to care > care management > transition - hospital case management programs can create a reference model to help identify the scopes of service and practice for a new model.  Eventually, given the CMS demonstration projects, it is anticipated that the definition for an episode of care will shift which makes it doubly beneficial to create a schematic representation of your current episode which can then be modified over time based on the dynamics of the hospital environment and the future focus of regulatory and payer perspectives.   



Each component of the acute episode of care has its own set of goals and related activities.  Some may overlap from one phase to another and some may require the expertise of a clinical professional while others are best delegated to non-professional colleagues.  Some of the activities may require chart review while others demand pro-active partnerships with the clinical team to advocate real-time on behalf of the patient.  Once you go through this exercise, you will be able to 'see' your scope of service, define your scope of practice,  and determine what activities are essential to achieve the outcomes you desire. 

When we started this newsletter back in 1994, we reported the difficulties in obtaining information about payer denials.  Hospitals simply could not provide actionable information to identify the source of their denials, the reasons for their denials, the amount of their denials by insurer, nor their actual denial rate (as a portion of expected revenue).  Fifteen years later, it still remains the most elusive financial metric in hospitals large and small!   



Denial data is the foundation of an effective denial prevention program.  Historically, third-party denial data was buried in contractual write-offs.  However, we know that write-offs are not reflective of the big denial picture.  Over the years we've identified several possible deterrents that may contribute to ineffective denial prevention:

1.  Fear associated with an admission that there is a denial problem.  We recall one executive committee that proudly reported a clinical denial rate of less than 2%. But during interviews with the business office managers, we discovered that the rate was more like 11%

2.  Sheer complexity of third-party denials.  The billing/collection process is indeed like a Rube Goldberg invention:   A complex device that performs a simple task in an indirect, convoluted way!

3.  Perceived inability to capture the denial data.  Legacy hospital accounting systems are partially to blame for this challenge although the old 'that's the way we've always done it' mentality is a contributing factor.

4.  Inadequate technology or infrastructure to support robust denial prevention.  In many situations, despite best efforts, the HIS lacks the ability to manage the denial notification process.  Today however, investment in this technology is imperative to stop the hemorrhaging, defend against the RACs, and to achieve complete contractual reimbursement.



There are a few hospitals that demonstrate a 'best practice' approach to robust data mining from the hospital's financial system to identify the amount of the account, the expected revenue (based on contractual rates), the denied amount (it could be an entire day, a specific service, treatment or procedure), whether an appeal should be written (if a case manager knows a day or treatment is potentially avoidable and a probable denial is inevitable, an electronic mechanism to alert finance needs to be in place), the appeal results, and the net reimbursement received.  



While there isn't a one-size-fits-all denial solution, the one common requirement for all is the data!  Accurate data-mining of denial data is potenitally the most critical element of a denial program and investing in technology to support this function is the only way to succeed.  

Several years ago a client customized their patient accounting system and cash application process to automatically capture and post third-party denial information from electonic remittances directly onto individual patient accounts.  The denial data could then be harnessed, tracked, and trended.  Together with the case managers' info on avoidable interventions and probable denials, the denial data was fed into the online collector workstations utilized for follow-up.  We understand that the system is still a work in progress but represents a rational and practical approach to what can be an intimidating initiative. 

We were delighted to meet many of our readers at the ACMA conference held last month in Boston and gratified by their kind words regarding the content of this newsletter.  Hospital case management is our passion.  Each member of our team is committed to a 21st century approach to hospital case management and are dedicated to help transform the old functional, UR & DCP models into progression-of-care outcome models. 



One of the hallmarks of a successful outcome model is the use of measurable outcomes that demonstrate the influence of the case management program.  Outcomes should not be confused with productivity metrics or task counts.  Outcomes must reflect the direct and indirect influence that the case manager exerts within the scope of his or her practice.  If you are a case manager working within the cardiology service line, then your outcomes should include measures that you've influenced over time through your interventions within that population.  Care provided in the hospital has to be effective and safe, and it also needs to be affordable.  Therefore, metrics should reflect as many of the practical components of the patient's progression-of-care through the acute episode....and beyond when feasible. Popular metrics include costs per case which reflect the efficient use of resources, which in turn determine margins.  Efficient delivery-of-care has a direct impact on length of stay which is a popular metric.  Delivery-of-care barriers not only affect LOS but also contribute to clinical and financial risk for the patient and the organization and may eventually impact the physician as well. 



The National Quality Forum is slowly shifting its focus from segregated clinical practices to episodes of care across a provider continuum using standards that will look at sets of measures within that continuum.  There are six areas that the NQF report as needing more focus and it includes care coordination; overuse of treatment; patient safety and reducing errors; palliative and end-of-life care; patient and family engagement; and improving the health of the populations.  Are your outcomes demonstrating your influence?

More and more payers are renegotiating payment contracts to fixed-rate reimbursement.  With some exceptions, fixed rate reimbursement is DRG-based.  And with DRG reimbursement, financial risk shifts from the payer to the hospital.  Once medical necessity is established, there is little incentive for the payer to insist upon continuing stay reviews which adds to their operating costs.  If your UR specialists are still doing continuing stay reviews for commercial payers with fixed rate reimbursement, the probability is that they are providing information for the payer's  data base more than providing information to determine continuing stay eligibility. 



The quality of documentation is the biggest challenge to confirm acute level of care and comply with medical necessity determination. The EDCM or Access Management team must confirm that medical documentation accurately describes the patient's medical condition, supports the service to be provided to the patient, and defines the reason for the service. Payers, including Medicare, consider medical necessity the key criterion that determines whether they will pay or deny a claim and they generally define it as 'services that are reasonable and necessary' and can only be provided at acute level of care. 



Medical documentation to confirm medical necessity and appropriate prescribed services are generally part of the EDCM's scope of practice.  With the help of a CDMP or concurrent coding professional it is key to a clean revenue cycle.  Hospitals that are still doing using retrospective processes - after the patient is a head in the bed - jeopardize their financial stability.

In the often cited science experiment, when a frog is placed in a pot of scalding hot water, it will immediately jump out.  But if the water is cool and heat is gradually applied, the frog will stay in the pot until it is ultimately boiled. This experiment underscores the danger of gradual change.  An organism is less likely to notice gradual change and therefore is less likely to react to the change, perhaps until it is too late.  On the other hand, being more obvious and uncomfortable, dramatic change usually causes the organism to react much more quickly and forcibly.  



With the increase in rapid changes in the environment, hospital case management programs now find themselves in a pot of boiling water.  The case management leader is a master at tweaking numerous dials, pulling levers at the right time, and expertly pressing the right buttons to adapt to new pressures.  But there is a problem inherent with maintaining a focus on optimizing case management workflow oprations:  It is diffifult to strengthen the current program while simultaneously inventing its future. 



Successful change does not just happen; it requires three key elements.  there must be awareness of an impending boiling pot, a compelling vision of the future, and a bridge between the two.  Planning a successful transformation is very diffult to accomplish while the pot is actually boiling, so don't make the mistake of waiting too long to begin.  Building awareness of the impending boiling pot and creating the compelling vision for the future will be the comparatively easy parts.  It is the bridge between the two that will require considerable forethought and careful planning to execute.  Progression-of-care is a very complex process involving a multitude of key stakeholders all of whom need to cross the bridge in unison.  You have to help them get there. 

Admission necessity has probably never faced more oversight.  From CoP compliance to RACs, from QIOs to MACs, pressure is mounting on hospitals to establish robust gatekeeping programs to establish inpatient medical necessity.  The admission decision ultimately belongs to physicians who consider factors like the severity of the patient's signs and symptoms and the medical preditability of something adverse happening to the patient.  But case managers positioned at points of entry can influence physician decision making by offering safe alternatives and help ensure compliance with accepted admission-screening criteria and federal regulations. 



One impressive high-tech resource is an effective ED tracker system.  These new systems provide lightning-fast computer access to passive 'white boards' that help EDCMs uncover delays in progression-of-care (treatment delays, order processing, & scheduling) and can identify patients for discrepancies in acute level of care criteria.  Passive computer systems uses RFID technology to automatically record and update the movement of patients, staff and equipment and have interfaces that quickly update the patient's ED record with every physician order and diagnostic result. These new systems significantly reduce data-entry which can otherwise burden the ED staff.  

Let's say you're the Director of a case management program in a large, community hospital.  Now let's say you are searching for a way to develop your case managers and promote teamwork among your staff.  You could schedule meetings to discuss ways to communicate.  You could organize a weekend retreat.  But even if you walk away with some fantastically innovative ideas, chances are you'll face the same challenge as many Directors before you:  creating a plan to implement those ideas.   That's where mentoring comes in.  Over the past few years, we've recognized that formal mentoring initiatives, with clear goals, are best to help staff learn and grow.   



The best mentoring initiatives also serve as educational opportunities.  The best we've seen consists of three phases.  The first is a routine 'lunch and learn' session held on the 'First Friday' of each month.  The Director, or an expert guest, leads a discussion about current healthcare/hospital issues and the group considers the relationship of those issues to  case management practice. The second phase consists of mid-morning huddles where team members get together and help each other by sharing successes and challenges and relating them to program goals.  The third track is a one-on-one mentorship generally initiated by the Director but which can eventually match case managers with each other in the more traditional mentoring setting. 



Mentors are leaders and because they are leaders they are also generally problem solvers - which, can create an odd paradigm.  When Directors, or for that matter any accomplished problem-solver,  assume a mentoring role, their first instinct is often to tell their proteges how to solve a problem.  But an effective mentor is able to shed the 'telling' role and don the role of a teacher to challenge and empower the mentee to think in new ways about old problems.  Hospital case managers practicing outcome case management must respond very differently to old, familiar situations.  The program's success depends on it!

The face of hospital case management and the role of the case manager have changed dramatically over the last few years.  Programs designed during the re-engineering craze of the 1990s are giving way to 21st century concepts to promote value, outcomes, and professional practice.  For the most part, discharge planning and utiliztion review functions are still aligned under the hospital's case management umbrella, but it is progression-of-care and outcome achievement that has taken center stage over the past five years.  



Progression-of-care (PoC) is often described as the basic building blocks of a case manager's scope of practice.  Within that scope are the components of CMSA's core processes.  A schematic of the PoC can serve as a reference model for any hospital case management program that desires to shift from task orientation (UR & DCP) to an outcomes orientation (bottom line results).  As hospital case management practice continually evolves to meet the dynamics of the hospital environment, so too may the scope of practice as well as the scope of service.  The graphic below is a snippet of a typical PoC schematic that is used to help identify and define the scope of practice and scope of service of a re-invented hospital case management program.

Access Management	Care Management	Transition Management
Level of care	Advancement of the treatment plan	Expectation planning
Community referrals from the ED	Physician practice behaviors	Clinical team consensus
Documentation coaching	System obstacles	Discharge screens
High-risk cases	Continued stay IS	Resource Center support

There is often overlap between each component of the acute episode of care, but for planning or evaluation purposes assume that each column represents a single PoC phase and assign each phase its own set of goals and related activities.  Once you go through this exercise, you will note that some of those activities require the expertise of a clinical professional while others are best delegated to non-professional colleagues.  Some of the activities may require chart review while others demand pro-active partnerships with the clinical team to advocate on behalf of the patient.  And finally, many of those activities will benefit from real-time partnerships with physicians while others require collaboration with colleagues within the hospital and the community. Once you go through this exercise, you will be able to 'see' your scope of service, define your scope of practice,  and determine what activities are essential to achieve the outcomes you desire. Good luck!

There are many ways hospital case manager assignments can be structured.  To fully advocate for the patient, monitor progression of care and maintain a consistent presence for the patient/family and physician, we generally recommend population based assignments in hospitals under 300 beds.  Hospitals with an ADC greater than 300 beds are generally best served with a hybrid assignment model. Population based assignments are organized around groups of specialty physicians, targeted patient populations, or specific DRGs.  Hybrid models integrate population based with geographic assignments.  



There are other variables to consider:  Has the hospital committed to a service line organization.  Service lines, Centers of Excellence, or business units [or by whatever name the hospital chooses], generally means that patients with similar diagnoses and in relation to their attending physicians are cohorted in a single geographic unit .  So, for instance, the cardiology service line patients would all be on one unit while the orthopedic service line patients would be on another unit.  



There are many benefits to regionalize patient occupancy.   The model of ICU medicine, L&D, and peds comes to mind. Each of those areas is designed to be a microsystem of convenience and efficiency.  Can that same principle be expanded to other hospital areas as safety, quality and cost issues take center stage?  Unless a hospital is functioning at greater than 100% capacity, we believe that a commitment to regionalization has benefits for both the hospital, the staff and the patients. 

We recently came across an article in Advance for Long Term Care Management  (Jan-Feb 2008) with the title "Safeguarding Against Falls" and were immediately drawn to a parallel issue in hospitals:  Payer denials.  Why is it that we don't see articles titled 'Safeguarding Against Payer Denials,' instead of "Denial Management."  We never encountered a "fall management" program! Does anybody else see the irony? Shouldn't the same logic that hospitals use to 'safeguard against falls' be applied to payer denials?  Why would we want to manage denials (a retrospective fix) rather than safeguard against them (prospective prevention)?   Just as every hospital should evaluate its patient fall risk factors, so too should it identify denial risk factors and identify appropriate steps to help reduce them. 



The Advance article used a table to identify "common fall risk factors and interventions."  We did a similar table for clinical denials which are typically directed to case management from the finance department.  To start, address each common clinical denial reason, and goodness knows, there are many that we've encountered:  Inappropriate admission; lower  level of care; non-acute pre-op day;  delay in discharge; quality of care; MD related; delay in procedure or test; insufficient UR; etc, etc.  If your finance department can't provide this information (and unfortunately, many cannot), you are at a significant disadvantage.  But if you are among the lucky ones, use the volume trends for each category to prioritize risk and for each risk factor, identify the probable cause and possible case management interventions. 

Once you have this report prepared, distribute it to your administrator, the CFO, the patient accounts manager, the revenue cycle team  and/or the revenue integrity department manager.  There are many causes for denials that are clearly beyond the positional authority of any hospital case manager to remedy.  But armed with this information,  the joint efforts of hospital stakeholders may be instrumental in driving change.  Good luck. 

1. The difference between an EHR and an EMR?  Last month, the Office of the national Coordinator for Health Information Technology (ONC) released a report defining the EHR as a patient-focused record while the EMR is a record set up by and for a particular health organization.  An EHR has interoperability - the ability to exchange information among and across many healthcare systems  while an EMR is designed to simply replace a paper medical record in the hospital and generally lacks interoperability.   Electronic medical records that cannot exchange information will eventually loose relevance and become obsolte over time.


2. Third party denial information is still illusive in many hospitals. But with the right tools and processes a denial information system is possible.  Investing in technology to support this function is no longer optional - it is a critical component of every hospital financial system because unlike so many other initiatives, the benefits of denial reporting programs are real and tangible including enhanced cash flow, reduced rework, decreased cost-to-collect, and more effective contract negotiations. It's that old cliche, 'if you can't monitor it, you can't manage it.'  With access to the facts of payer denials, front-line case managers are better able to prevent them in the first place!


3. Under the 9th SoW, which goes into effect 8/1/08, the QIOs will be required to conduct 85% of their work in certain hospitals being targeted as in need of improvement in their surgical-care measurements. The list of targeted facilities can be found at   http://www.cms.hhs.gov/QualityImprovementOrgs/downloads/HospitalChart.pdf


4. Internal hand-offs between and among case managers, hospitalists, medical residents and nurses continue to present challenges and the few studies that have researched the problems have all found that the process is "variable, unstructured, and prone to error."  According to one study, 26 interns caring for 82 patients reported 25 discrete incidents that led to repeat or unnecessary tests. We have found that standardization of the hand-off process works.  Even a simple written form or computer template can go a long way in making sure that critical information such as code status, outstanding diagnostics or active and anticipated medical problem is not left out. Requiring that handoffs and signouts include a face-to-face conversation takes the process a step farther because even the most experienced provider can fail to adequately communicate the unpredictable nature of hosptial care. 

(This article is presented with the permission of its author Ronald Hirsch, MD.  It was written for the Sherman Hospital Case Management newsletter and intended for its medical staff. 



Has this ever happened to you? You are just about to leave the exam room at the office after a long visit with a patient. You have adjusted some medications, counseled about their disease process and ordered lab tests. As you walk out, the patient says, “By the way, doc, I have been having trouble with my knee for the last 6 months. Can you take a look?” You know that addressing this could take another 10 minutes so you ask the patient to schedule another appointment.

In the hospital the same thing happens but with the tables turned- you admit a patient for an acute illness and “while they are here” you order an evaluation for another unrelated stable problem.

Here’s an example of a patient from May. An 80 year old female was admitted for exacerbation of COPD. She received excellent care from her physicians and improved. But it was noted that she was mildly anemic on admission with a Hb of 10.6. GI was consulted and thought it may be dilutional but continued to follow. In Cerner it was noted that in January her Hb was 10.4. After 8 days, her respiratory condition stabilized and GI wrote for the colonoscopy prep. But it was Friday before a holiday weekend so she sat for 3 days. Then the first prep was inadequate so it was repeated that evening for another scope the next day. An adenoma was found, iron ordered and she was discharged.

The hospital charges for this patient will be submitted with the DRG for respiratory system diagnosis. In the five days she waited for her colonoscopy, she incurred over $25,000 in charges with no change in her DRG payment to the hospital.

Since her respiratory status was stable, if the Medicare Peer Review Organization (PRO) were to review this chart, they most likely would deny the physician charges submitted for those days.

So as you treat your hospitalized patients, be sure that you are providing care in the proper setting.

In 1967, Jack Wennberg, a young medical researcher at Johns Hopkins moved his family to Vermont to run a new program at the University of Vermont examining medical care in the state.  He traveled the state, collected data on procedures and came up with an odd finding: Medical practice across the state varied enormously.  In Middlebury, for instance, only 7% of children had their tonsils removed but in Morrisville, 70% did.  More research and more data collection followed to see whether different patterns of illness could explain the variations in medical care.  They couldn't. The children in Morrisville weren't suffering from an epidemic of tonsillitis. Instead they happened to live in a place where a small group of doctors had decided to be aggressive about removing tonsils.  The stunner however, was that Vermonters who lived in towns with physicians who treated aggressively were not healthier than other Vermonters - they were just getting more medical care. Dr. Wennberg eventually moved to Dartmouth where he and his colleagues have conducted versions of this original study again and again and come up with the same result.  Their well-respected research is published periodically in the Dartmouth Atlas and demonstrates time and again that the US spends more money on healthcare per person than any other country, but we are not healthier. 



This anecdote, which we first encountered in Michael Millenson's great book Demanding Medical Excellence, is now the backbone of another great book Overtreated:  Why Too Much Medicine Is Making Us Sicker and Poorer by Shannon Brownlee, a senior fellow at the New America Foundation and former writer for US News & World Report.  The book paints a clear description of the dynamics of the healthcare economy and is filled with information on care that brings no health benefit and worst of all, often causes harm.  We just finished reading it and recommend it for your library, or even better, as a gift for your favorite doctor! 

Successful hospital case management programs achieve and sustain their value position by delivering 'extraordinary levels of distinctive value' to carefully selected customer groups every day.  That's how Tricia Howard describes the success of her program in Jacksonville, FL.  "To be successful," Tricia wrote us, "we had to have a strong focus and be able to distinguish ourselves from our competitors down the road."

Tricia cites three distinct principles she uses in her program:

1.  Operational excellence.  Tricia reports that under the old UR/DCP model, her team tried to be all things to all patients and all physicians and it was impossible.  "I had a high staff turnover as they tried to do all the stuff that the exec team thought we should be doing."  Tricia developed a business plan with a consistent range of services to a selected population that was agreed upon the the C-suite and reports that she hasn't had a vacancy in 3 years. "It was important that we practiced consistently so that our customers didn't get confused.  We asked the same or similar questions, we queried the same practice and process issues, and we used the same resources to resolve cost and quality issues."   

2.  Customer intimacy.  When Tricia was recruited to the Director role, the staff were managing medical charts.  "We did a mini engineering study and found that 74% of the case managers' time was spent reviewing medical records." That left little time to work with the physicians, patients, and nurses.  In the business plan she developed, she envisioned a close working partnership with selected physicians, their patients and respective nurses.  "In the first year of our new model, the nurses were most challenging.  They were used to the case managers being on the units all the time and often used them to augment their practice.  When the case managers disappeared, the nurses reacted and we had to deal with a lot of negative publicity for nearly three months until the physicians saw the benefits of the new model and served as our champions."  In addition, because the new model provided case management serrvices to only selected populations, the nurses had to adjust to managing their patients from entry to exit, "something they weren't used to doing under the old model" says Tricia.

3.  Program Innovation.  The case management team now performs in harmony but they are constantly on the look-out for new ideas and new ways to meet organizational expectations.  Tricia said that "The team is now pretty self-sufficient and look to me to bring their suggestions and recommendations for improvement to the leadership group." For example, the team recommended incorporating a portion of the quality review positions into the resource center positions to reduce redundant chart review activities. Not only was this a cost saving measure, but the information obtained on a concurrent basis was shared with the case managers to immediately bring to the physician's attention.  

With Thanks to Tricia Howard for allowing us to share her email.    

A few years ago we encountered a hospital that assigned a seasoned nurse on a rotating basis to the emergency department to jump-start the initial patient assessment.  It seemed like a creative idea to provide senior clinical nurses an opportunity to experience a new environment, to learn first-hand the importance of an accurate and complete assessment, to gain exposure to the challenges of moving patients through a busy ED and to participate in the gatekeeping functions. On the other hand, there are probably as many detractors to this idea as there are proponents.  

Now comes a similar practice that is beginning to surface among hospitalist groups: Rotating hospitalists into the ED to serve as the admitting physician. This practice too, which we are just starting to encounter, has its supporters and detractors.  On the plus side it would certainly cut down on the number of interruptions that hospitalists encounter during inpatient rounds.  It also would keep the hospitalist's focus on both the clinical and business considerations that constitute the gatekeeping function. The consistent presence of an admitting hospitalist makes it easier for the EDCM to 'educate, inform,and counsel' on many of the business issues that often impact level of care decisions for both the patient and the physician. And finally,it would enable the rounding hospitalists to devote their full attention to their patients.

On the other hand, it increases the number of 'hand-offs' that we know to be a source of many hospital errors and due to the unpredictability of inpatient census or admission volume, especially in smaller hospitals, it may create an unequal distribution of work responsibilities. 

The verdict is still out whether this practice will gain popularity. We can envision that the model would be very popular in hospitals with busy inpatient and ED admission volumes. If an ED is admitting between 30 - 60 patients a day, having a dedicated admitting physician might very well be worth it.   

The role of the emergency department case manager [EDCM] is among the most frequent questions we receive via your emails.  At your request, we are pleased to clarify our encounters with successful ED case management programs.  Successful ED case management programs function primarily as gatekeepers for the facility.  The principle is based on the fact that every patient who walks into the ED does not require an inpatient admission to treat his or her immediate needs.  The EDCM provides supplemental information to the clinical team prior to beginning the admission process to ensure that the patients' needs can only be met at the acute level of care. Objective information must support that determination because without it, the hospital and perhaps the patient, are put at risk.  The EDCM is best prepared and positioned to provide information about the correct billing status (inpatient or outpatient/observation) and can collaborate with the bed management team (or whoever is responsible for elective or direct admissions) to identify opportunities to avoid using inpatient days for services that can be more safely and cost-effectively provided on an outpatient basis.

The EDSW on the other hand, generally works with ED patients who present with social or educational needs. These complex populations are often the cause of ED backup and make up the largest segment of return visits.  The EDSW can facilitate creative transportation, make referrals to community social services, find follow-up medical or dental care for unfunded patients, locate safe havens for victims of domestic violence, and assist patients with innovative solutions to obtain clothing, food, medications and equipment.   "Social admissions" of elderly patients who can no longer care for themselves at home and have no acute medical needs can be significantly reduced through the efforts of the EDSW.

The dyad model of hospital case management - typically, a case manager partnered with a social worker - is a costly approach and we do not routinely find it in community hospitals. However, the combination of an EDSW and an EDCM dedicated to the emergency department is an asset worthy of investment by every hospital no matter what the size. 

The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is a valuable resource containing hospital-specific Medicare claims data statistics for target areas that have been identified by the CMS as high risk for payment errors. These target areas include one-day stays, hospital readmissions and several DRGs that have historically been associated with payment errors.

PEPPER uses hospital-specific percentiles for each target area to determine "outlier values" typically reported as exceeding the 10% The outlier values reveal how unusual a hospital's findings are, relative to other hospitals in the state. Positive outlier values indicate possible overcoding or questionable medical necessity of admission, and negative outlier values indicate possible undercoding.

PEPPER helps hospitals identify areas in which there may be opportunities for compliance improvement.  Over the last few years, we have found that only a smattering of program Directors know the existance of PEPPER and even fewer with whom the reports are shared.  Do yourselves a favor....ask about PEPPER in your hospital.  Ask to see a copy of the report.  If you are using a physician-centric model, PEPPER information can be very valuable in terms of helping a physician stay 'under the radar' by documenting more accurately.  If you are using a 'targeted' model (see article below), PEPPER can assist in identifying high risk diagnoses and if you have a robust EDCM program, level of care discrepancies would be good information to strengthen gatekeeping initiatives. 

• From Margaret Freundl in Warren, MI - Contracting with an external physician advisor to support gatekeeping activities. The physician augments the work of the EDCM to ensure qualified admissions. Patients in the ED as well as direct admits from the physician offices are often referred to the physician advisor when differences surface. Due to compliance issues, they began by focusing on Medicare patients but are now ready to take the next step and focus on all admissions.
• From Sue Barlow, Warrensburg, IL - Our best idea was the creation of a centralized Support Station to handle all the clerical and chart review activities that we've had to do since the inception of our program in  1999. "This has freed up the case managers so we can now show how we have reduced costs and generated revenue for the hospital". Sue reports that each case manager just got personal Blackberries as a thank-you gift from their CFO.
• From Barb Dalenberg, IL - The community has a large self-pay population who often present themselves to the ED. Barb reports that they recruited a retired Public Aid counselor who now works as an EDCM and targets every self-pay patient to begin the process of applying for public assistance. "These are patients we would probably have missed," Barb reports.
• Sharon Dimit, West Valley City, UT reports that putting an EDCM in place is the best idea they had to improve their gatekeeping responsibilities. They are now shifting some resources within the program to cover the ED on a 24/7 basis.
• Dot Perez reports that "saturating the medical staff with information as well as quarterly report cards" have been effective strategies to get physician buy-in to the case management program at her facility.
• Crystal Redding of Winston-Salem NC boasts that the data she captured and quantified concerning non-qualified and social admissions through the ED led directly to the organization's investment in EDCM and EDSW FTEs. They continue to capture data and turn it into information to demonstrate how case management interventions in the ED has improved ED capacity and patient flow.

Source: With many liberties from Glaser and Garets, Healthcare Informatics, 2/06