Kowinsky, Amy RD, LDN; Greenhouse, Pamela K. MBA; Zombek, Victoria L. BSN, RN; Rader, Sandra L. DNP, RN; Reidy, Margaret E. MD
With shorter hospital inpatient stays and more acutely ill patients, providing high-quality, well-coordinated care across the continuum is a challenge for healthcare providers. Care management encompasses the full spectrum of coordination of patient care, including in-hospital treatment, referring patients to the next level of care, and ensuring adequate follow-up care. Care management also includes addressing increasingly burdensome insurer and governmental regulatory requirements.1-4 Typically, care managers (usually nurses) and social workers (masters in social work [MSWs]) jointly form the foundation of patient care management. However, unclear role delineations and the increased emphasis on financial/regulatory requirements, in some cases, have resulted in a general decline by both disciplines in time spent with patients and families and in time spent communicating with physicians and other caregivers.
Many hospital leaders are redesigning their care management processes, with new models taking a variety of forms4,5 intended to address the balance between patients' care needs and the utilization review functions required for payment. At the 517 licensed-bed, tertiary University of Pittsburgh Medical Center (UPMC) Shadyside, redesign of the care management function was initiated in 2006, with the goal of increasing the time that care management staff spend with patients, families, and physicians while supporting essential metrics such as length of stay, payment denials, patient satisfaction, and cost of care.
The care management model at UPMC Shadyside from 2002 to 2006 involved primary care coordinator (PCC) nurses (BSN or MSN prepared) responsible for all patient care coordination, discharge planning, and utilization review (insurance) functions. As insurance requirements increased in complexity and volume, however, less time became available for the PCC to spend with patients and families and to communicate with the rest of the professional care team. While UPMC Shadyside had one of the lowest payment denial rates in the country (<1%), it became more and more difficult for the PCC to balance all aspects of care coordination and discharge planning with the utilization review functions of calling payers, identifying and verifying available continuum of care beds, and completing associated administrative work.
Baseline observation in late 2006 showed that PCCs were spending 59% of their time on insurance tasks and 9% of their time with patients (Figure 1); MSWs who are specifically trained to address patients' psychosocial needs were spending a majority of their time on discharge planning tasks, some of which were not complex and did not require their expertise. In addition, some tasks of the PCC overlapped with social work roles, resulting in work redundancy, work omission associated with unclear accountability, and/or delays in care.
A care management redesign pilot was initiated with a team of hospital leaders, PCCs, social workers, unit directors, frontline nurses, and improvement specialists from the UPMC's Donald D. Wolff Jr Center for Quality Improvement and Innovation. The primary goal was to address the need for greater communication with patients, families, physicians, and with coworkers across disciplines to promote more effective and efficient patient care. Hospital leadership was committed to finding a solution that would better meet the needs of its patients, families, physicians, and staff and allow the hospital to maintain its success from an insurance perspective.
Care Management Redesign Model
The new care management model involved splitting the insurance work from the care coordination/discharge planning duties by defining new roles for both PCCs and MSWs. In the new model, there is an insurance PCC responsible for completing all insurance functions and a care coordinator/discharge planning PCC responsible for completing all care coordination and discharge planning functions. Care coordination duties involve ensuring that the inpatient's care plan is managed appropriately (eg, required consults are obtained in a timely manner, verifying that correct medications are ordered and received, ensuring that discharge options are appropriately assessed, etc) throughout the inpatient stay; discharge planning duties involve either coordinating placement and transport to the next level of care or, if the patient is going home, consulting home healthcare and the infusion company (if needed), obtaining prescriptions, and ensuring that all required predischarge testing and laboratory work are completed in a timely manner. Both of these PCC roles are filled by nurses. The care coordinator/discharge planning PCC's role in the redesigned model also includes daily visits to all patient rooms and daily rounding with physicians and nurses. MSWs, in the care management redesign model, work from a trigger list with a focus on the complex placements and psychosocial issues for which their specialized education and training prepare them such as crisis intervention, lack of family support, homelessness, abuse, and the need for psychiatric or department of corrections involvement. They no longer perform routine discharge planning.
This new role delineation, which was labor cost neutral (there was no change in the total number of PCCs and MSWs), takes the care coordination/discharge planning PCCs away from the computer screen where much of the utilization review and discharge planning had taken place and gives them more direct time with patients and families, as well as with other members of the healthcare team. Direct communication with patients and families provides an opportunity for greater understanding of the patient's needs and the time to address them, as well as providing patients and families more opportunity for input into their care and discharge plan. Furthermore, the redesigned model of care provides professional "ownership" to each patient's case so that the patient's needs are met with an optimal level of accountability.
In the new care redesign model, the care coordination/discharge planning PCCs are unit based with a patient volume of 15 to 20 patients each, down from the 25- to 30-patient caseload in the previous model. The new model also provides for 4 floating insurance and care coordination/discharge planning PCCs. In the previous model, with no floats, work was further fragmented by coverage needs. In the current model, the floats provide ongoing coverage. Furthermore, the nonfloating PCCs rotate as floaters periodically to remain fresh and to provide for professional growth.
The new roles were piloted on 4 medical-surgical units in December 2006 and January 2007. Results showed a 144% increase in PCC (care coordination/discharge planning) time spent with patients/families, a 200% increase in PCC time spent with physicians, and an 82% increase in PCC time spent with nurses and other caregivers. In addition, the role changes gave the utilization review PCCs the opportunity to focus specifically on creating more efficiency in documentation. Whereas in the previous care management model documentation was often voluminous as the PCCs and MSWs sought to document thoroughly and cover all bases, in the redesigned model the insurance PCCs developed value-added documentation limits for both content and frequency of documentation, resulting in a 48% decrease in the amount of PCC time spent in documentation activities.
Comments received about the new care management process included the following:
* From a unit director: "There is great communication going on, the best I've seen in years." This is in large part due to the fact that the new care management structure provides the care coordination/discharge planning PCC more time on the patient unit and less need to be pulled in other directions including time spent at a computer.
* From a patient: "I have had several pleasant exchanges with the [care coordination/discharge planning] PCC. Most recently, she explained my PICC line and how home care would be set up. It seems a position like that… a central point of contact… would be even more helpful for families than patients. I may be tired and only tell my family one part, the physician may tell them another part, but it is good to have one person who has the whole story that my family can talk to. I have been surprised with how current the info is that she has when she comes to see me." In the old model, the PCCs were rushed and spent too much time at the computer to spend much time at the bedside; now, patients and families have significant face time with the care coordination/discharge planning PCC.
* From a staff nurse: "The PCC on the floor has always been good, but now it is easier; she is coming to me more. We have better communication."
* From a physician: "I have only been on the floor for a few weeks, but I know who is doing the care coordination and discharge planning. She is great and talks to me every time I'm here. Three of my patients have commented about her… I can see they definitely have made an attachment to her."
The new care management model was spread to the rest of the hospital in February and March 2007.
In April 2008, 1 year after the care management model redesign was spread housewide, data collected through direct observation (32 hours) by improvement specialists and by the care coordination/discharge planning PCCs, and through staff, physician, and nurse surveys, showed sustained success in meeting the defined goals of the redesign.
Direct observation on 4 patient units showed that PCC time spent with patients/families increased from 9% at baseline to 22% at the time of implementation and 19% 1 year later, a 111% increase. The time PCCs spent collaborating with physicians increased from 3% at baseline to 9% at implementation and 8% 1 year later, a 167% increase. Time spent by PCCs collaborating with nurses and other caregivers increased by 182%, from 11% at baseline to 20% at implementation and 31% 1 year later. Patient satisfaction with discharge, based on Press Ganey reports, increased from 81.9% for the fourth quarter of calendar year 2006 to 84.4% for the fourth quarter of calendar year 2007 to 85.5% for the fourth quarter of 2008. Patricia Thomas, writing in the Journal of Nursing Administration in January 2009, found that "caseload distribution and role definition had a statistically significant impact on length of stay and denial management."6 Length of stay at UPMC Shadyside has shown a steady decline beginning shortly before housewide implementation of the care management redesign model (Figure 2). A conservative estimate of the dollar savings associated with this decreased length of stay is $440,000 in fiscal year 2008 alone (144,915 patient-days in fiscal year 2007 vs 143,311 patient-days in fiscal year 2008 × $275/d). The payment denial rate has been maintained at less than 1%.
Care management staff (PCCs and MSWs) reported a 28% increase in the "agree or strongly agree" category when answering the survey question, "I feel in control of my day," from 55% at redesign implementation to 70% 1 year later. Overall satisfaction with the care redesign model increased from 71% at implementation to 78% 1 year later for PCCs and MSWs and from 83% to 93% for physicians/unit directors. Ninety-seven percent of physicians/unit directors rated communication with the care management staff as good/very good 1 year after implementation, and 87% agree that patients have been positively impacted by the model redesign.
Despite the positive outcomes, both the PCCs and MSWs involved in the care management redesign at UPMC Shadyside have identified ongoing challenges. Primary care coordinators (both care management/discharge planning and insurance) are still faced with an abundance of paperwork, related to increasing regulatory (eg, core measure)7 and financial requirements. The caseload for the insurance PCCs continues to run high-up to 30 cases per coordinator. It is reported by MSWs that referrals too often arrive late (both late in the day and late in the patient's stay), and there is still some overlap occurring between MSWs and care coordinators.
Given these challenges and the desire to continually refine the program to best meet patient needs and the ever-changing regulatory environment, the care management redesign team is working on further defining the MSW and PCC roles. The team is also working with the therapies' staff (physical therapy, occupational therapy, respiratory therapy, etc) to define a process for identifying high-priority patients for both treatment and documentation. Plans are under way to evaluate opportunities to spread unit-specific best practices in work assignments hospitalwide and to work with the health system's affiliated health plan to remove barriers to early discharge (eg, withholding authorization until the day's physical/occupational therapy notes are documented). Finally, the team is evaluating the best possible location for the PCCs on the unit, because accessibility impacts interactions with staff, with physicians, and with patients/families.
The needs to improve the quality of healthcare being provided today8,9 and to use professional resources wisely are priorities among healthcare leaders nationwide. Balancing quality care delivery with the hospital's financial bottom line is an additional challenge. Redesigning care management to most effectively and efficiently meet patient need is an essential factor in both improving healthcare delivery and maximizing reimbursement.
The care management redesign model implemented at UPMC Shadyside has improved time spent with patients, families, and physicians, while patient and staff satisfaction has increased, length of stay has decreased, and payment denials have remained among the best in the country. With gains still in place 1 year after redesign, the care management redesign team continues its work to address remaining challenges and to push for continued success in meeting the ever-changing healthcare environment.
© 2009 Lippincott Williams & Wilkins, Inc.