Utilization And Case Management At A Hospital

Utilization And Case Management At A infirmarySierra View District Hospitals (SVDH) utilization review (UR) attend originates in the Case Management (CM) department. They ar responsible for the case review and obtaining social services for those endurings in need of services. This paper leave behind describe how this process whole kneads and how SVDH compares to another facilitys UR structure. There pass on also be a discussion about the weaknesses of the SVDH program.Utilization Management at SVDHThe CM department is responsible for the UR process at SVDH. This department, which has 13 employees, is staffed as follows four Case Managers two licensed clinical social workers four social services worker a surgical incision Analyst and a Wound Care Specialist. An Administrative Director oversees the department.The CM department follows a Utilization Review Plan (Appendix A) which establishes how the CM department will review cases and address potential discrepancies from establis hed best practice guidelines like McKessons InterQual Criteria (McKesson, 2010). The four Case Managers are to conduct concurrent reviews on whole Medicare admissions. They respect the uncomplaining chart and documentation to ensure the correct medical care view of Inpatient or Observation Services is assign to the patient. If the patient is assigned the correct condition wherefore the Case Manager will flag the case for review in three to four geezerhood to ensure the situation of the patient has not changed to such a degree that either a higher or lower service take aim is required. If that is the case, the manager will see the primary care doctor and seek an order changing the service level. If the medico does not agree, and the documentation in the case ceases to support the current level of care, the case manager will forward the case to the physician advisor for review. If the physician advisor agrees that a new level of care is called for then he/she will contact the physician to seek further clarification as to why the patient needs continued services at the current level. Depending on this conversation, at that place are four possible outcomes for the patient status. One, the patient status will remain at the current level of care because the initial physician has informed the physician advisor of extenuating circumstances regarding the case. Two, the physician will agree to the conversion of the patient status to either a higher or lower level of care. Three, the physician will not agree with the physician advisor, and the advisor will refer the case for the UR committee for a panel decision, which clear overrule the original physician or Four, the patient can be discharged from the hospital.While Case Managers are working the UR of a patient, the Social Workers are concerned about any after-care the patient may require. The Case Managers and Social Workers work together to come up with a discharge plan kickoff on the first day of adm ission. The Social Workers make sure the patients get hold of all the contact information they may need once discharged, and the Case Managers work to ensure placement of the patient in an extended recovery care facility if needed.SVDHs UR design Compared to Other HospitalsSVDHs UR program is comparable to that of Jewish Hospital (St. Louis). introductory to 1985, the Center for Medicare and Medicaid Services (CMS) reimbursed hospitals for services rendered. Due to increasing costs to the Medicare Trust Fund, the Diagnostic Related Group (DRG) system was developed to reimburse hospitals based on what the average cost of a particular surgery. UR programs at both hospitals began to change to meet the new challenges instituted by CMS. Utilization Review became Case Management at SVDH, while Jewish Hospital named their program Case Coordination. The staff members at both facilities became more involved in complete patient care, from admission to post-discharge. SVDH experient the sa me growing pains that Jewish Hospital did when Observation Services became a new cost savings service line instituted by CMS.The beside challenge arose in 1990, when quality initiatives arose. These initiatives have tho increased since that time, with the establishment of Quality Initiative Organizations (QIO). The QIOs review hospital data and report results back to CMS. The end of these organizations is to locate services that do not meet their (CMS) standards. When found the QIO will deny payment for the services. While Jewish Hospital attempts to complete a coulomb% review for quality indicators on all cases, either concurrent or retroactive, SVDH chose to focus 100% on Core Measure cases only. While Jewish Hospital mogul be ensuring that all cases have a minimum standard of quality, SVDH complies with Joint Commission standards by only reviewing the Core Measure cases.Weakness of the ProgramThere is a major weakness in the SVDH Case Management program, and it has been a w eakness for some time. SVDH CM is not a 24/7/365 program. The Case Managers work Monday through Friday from eight to five. One Case Manager works from eight until noon on Saturday in the emergency room, but there is no coverage on Sunday. This means that the one Case Manager only reviews the cases that were admitted from Friday at 500 PM until 800 AM Saturday morning. If she has time she will also pick up any additional cases she can prior to leaving at noon, but there is no guarantee of that happening. The entire CM staff will review any cases not previously reviewed on Monday, if the patient is still in-house, or the case will undergo a retrospective review. This can cause continuing care problems for patients.An example of one of these problems recently occurred when a patient was not reviewed due to no CM personnel on staff on Friday evenings. The patient presented to the Emergency Room on Friday, and was subsequently placed in Observation Services at the hospital, This case was not reviewed by the weekend case manager. On Monday morning, the CM personnel started reviewing the Medicare admissions and saw this patient on the CM list. In reviewing the chart, the patient plainly met Inpatient criteria. The attending physician could not be contacted so the case was referred to the physician advisor, who agreed the patient should have been classified as Inpatient. The status was changed as of Monday morning. CMS guidelines state that a status can only be changed upon the presentation of an order, and at no point can an Observation Services case be converted to an Inpatient status retroactively. The patient needed additional therapeutic services that would be provided in a long term care facility, but CMS guidelines state that Medicare will only pay for those services if the patient has had a qualifying Inpatient sojourn in a hospital for a minimum of three calendar days (Centers for Medicare Medicaid Services, 2009). Since this patients status converted to In patient on Monday morning, the time spent in the hospital from Friday until conversion on Monday did not count towards the qualifying stay. The quandary then is to either discharge the patient to the care facility without a qualifying stay, thereby making the patient responsible for the entire cost of the care, or property the patient in the hospital for an additional two days in order to meet the qualifying stay requirements. The obvious answer is to keep the patient in order for them to obtain the necessary time to earn the qualifying stay. This, however, places a bed out of circulation that could have been used by another patient, and might incur costs that do not meet reimbursement criteria for the hospital. Had a CM staff member been on duty Friday night, the case could have been caught earlier, and the qualifying stay could have begun on Friday instead of Monday.The major obstacle to hiring more Case Managers is, frankly, the cost of salaries. Any additional overhead costs ar e scrutinized closely in these times of shrinking reimbursements. Prior to bringing on new staff, in any area, the return on the investment is reviewed for a goodability margin. If a profit margin cannot be realized then the likelihood of incurring that additional expense is small. Other projects that bring a greater profitability margin have taken priority over additional staff in the CM department.ConclusionThe CM Department administers SVDHs UR program. The CM Department encompasses several different services, all dedicated to providing total care to the patient while in the hospital and post-discharge. SVDHs program mirrors common practices within the industry. Like Jewish Hospital (St. Louis), CM at SVDH has evolved and changed over the years to meet the new demands placed on it by regulatory agencies. The CM Department constantly works with physicians to ensure patients receive the book level of care based on physician documentation and InterQual guidelines. The major weakne ss in the CM program at SVDH is that it is not a 24/7/365 department. This flaw sometimes places the continuum of care for the patient at odds with the regulatory guidelines, and SVDH has to forego reimbursement for services in exchange for better overall patient care and patient financial security.