Critical Path Network: Electronic CM system optimizes data, patient flow
Critical Path Network
Electronic CM system optimizes data, patient flow
Software, data reports are standardized throughout the region
Sutter Health's Sacramento Sierra Region's customized electronic case management system with embedded InterQual criteria enables the case management department to track everything from individual case manager performance to regional outcomes.
The computerized case management system is an integral part of the hospital system's quality improvement process and includes quality and risk measures, publicly reported metrics, safety measures, adverse event reports, and other measures of physician and case manager performance, says Michael Avriette, utilization management executive for the seven-hospital region of Sutter Health, with headquarters in Sacramento, CA.
The Sacramento Sierra Region includes hospitals ranging in size from rural hospitals with 20 beds to larger metropolitan ones. All of the directors or managers of case management at the seven campuses report to Avriette. The information technology staff who support the software system are part of Avriette's department.
At one time, many of the hospitals in the region were using individualized versions of the software, Avriette says.
"We knew we had to create a standardized software system so we could measure apples to apples across the region," he says.
A team of case management representatives from all the hospitals in the region worked to standardize and integrate the case management software and processes.
"Together, we have standardized the data definitions, the software, and the reports. The reporting is the same at all the hospitals. We also use the same software for reporting on our dashboard," Avriette says.
All of the documentation, discharge planning, utilization review data, and insurance information is integrated, he adds.
Avriette uses the software system to create reports showing everything from meeting utilization review goals to the percentage of stays longer than 10 days and sends a monthly scorecard to the vice president of medical affairs, managers and directors of case management at all hospitals, the hospitalist groups, every case manager and social worker, and the hospital system's regional CFO.
"The information on those reports is part of our performance evaluation for the system as a whole, for each director, and each individual case manager and social worker. It enables us to identify when things are working and when they are not. We see how we are doing on a monthly basis so there are no surprises at the end of the year," he says.
At Sutter, when case managers log on to their computers, they pull up a work list that is populated with information about the patients they need to see that day, including admission reviews and continuing stay reviews.
If the case manager previously missed a field when conducting an insurance review, it is included on the work list.
The case managers review patients to make sure they meet InterQual criteria and fill out severity of illness and intensity of service check boxes.
"The documentation is all done electronically. The case managers use mobile laptops and a web-based program so they can complete their documentation wherever they are," he says.
When a patient doesn't meet acute care criteria, if there is a medical necessity issue, the software automatically forwards the information to the physician advisor.
If there are issues, such as delays in service, the case automatically goes onto a work list for the case management director or manager to review.
The hospital system has created a case management intensive course that the staff development manager used to educate the staff when the software system was rolled out and now uses to train new staff.
New case managers go through an intensive two-day course and three days of shadowing. Then they work with a preceptor for six months.
"At the end of the week, they know how to access the software and perform the basic case management tasks. Then they can call the preceptor at their site for help," Avriette says.
The hospital's case management software and discharge planning software are integrated so that when the case manager has completed the discharge plan, all of the information is easily transmitted to post-acute referral sources.
"We use the software to track how often the referral sources say yes and how long it takes to get a referral," Avriette says.
"Retrospectively, I can look at the data and see how many referrals we sent to specific providers, how many times they accepted the referral, and how many times they said no and determine a pattern. For instance, we can tell if a vendor is cherry picking only patients with good payers," he says.
Using the automated software system helps the hospital comply with Medicare's patient self-determination requirements, he says.
The software has a prompt embedded in the discharge planning portion that asks the case manager to check off that the patient was informed of his or her right to choose a post-acute provider and was given a list of providers.
At Sutter Health, directors and managers of case management and individual case managers have individual goals that are aligned with each hospital's goals and systemwide goals.
For instance, case managers are responsible for case management, utilization review, and discharge planning and have a goal of assessing all patients within 24 hours of admission.
The case management software system automatically creates reports that measure how well the goal is being met by hospital, service line, and individual case manager.
"We have integrated managerial reports so a manager can see at any given point whether the individual case managers are meeting their goals," Avriette says.
The hospital system uses the software to track everything from service delays to medical necessity issues referred to the physician advisor.
"I can generate reports by case manager or by physician advisor and monitor quality by identifying patterns. I can easily generate a report showing how many patients didn't meet InterQual criteria, how many cases were referred to the physician advisor, and whether they were upheld or overturned," Avriette says.
He uses the data to identify practice patterns among individual physicians and provides information to the hospitalist groups at each hospital on which physicians are admitting patients who don't meet criteria or who have not discharged patients and how they compare to their peers at other hospitals.
For instance, Avriette can determine how physician advisors compare with their peers at other hospitals when it comes to approving admissions that don't meet InterQual criteria.
Avriette uses the software to track length of stay and the percentage of patients who don't meet continued stay criteria.
"We can look at this by hospital or by individual physician. If one hospital has a higher rate of patients who don't meet continued stay criteria, we can look at physician practice patterns and intervene if necessary," he says.
Avriette uses the data he receives to identify educational opportunities for the entire case management staff.
For instance, the hospital region has conducted educational sessions on the appropriate use of InterQual's "Guidelines for Surgery and Procedures in the Inpatient Setting," also known as the "inpatient list."
"These guidelines are confusing because some subsections of a procedure will qualify for an inpatient admission and some will not," Avriette points out.
For instance, pacemaker insertions do not qualify for an inpatient admission unless they are urgent or inserted by thoracotomy, he says.
"We determined that people were not using these guidelines properly, so we've conducted a lot of education on this issue," he says.
(For more information, contact Michael Avriette, utilization management executive, Sacramento Sierra Region, Sutter Health. E-mail: [email protected].)
Sutter Health's Sacramento Sierra Region's customized electronic case management system with embedded InterQual criteria enables the case management department to track everything from individual case manager performance to regional outcomes.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.