Contract managers help with high-volume DRG
Contract managers help with high-volume DRG
Vendor supplies follow-up analysis
With an average length of stay (LOS) of about seven days for their high-volume joint replacement population, physicians at Lakewood Regional Medical Center of Long Beach, CA, realized that they needed additional resources if they were to cut LOS to under four days without sacrificing their high quality of patient care.
In particular, they identified a need for better collection and analysis of outcomes data, thorough preoperative screening of joint replacement enrollees, and a plan providing for home health and follow-up assessments to reduce the likelihood of postoperative complications, says Robin Tufono, RN, a clinical case manager at Lakewood.
Because instituting such changes independently would tax Lakewood Health Plan’s resources, the plan turned instead to a third-party case management company to provide management services for its orthopedic population. As a result, LOS for total hip replacement has dropped from an average of seven days to an average of three days.
The company, MedSmart International in Costa Mesa, CA, also assisted in the development of Lakewood’s updated joint replacement pathways.
Lakewood orthopedist Perry Secor, MD, worked with MedSmart in developing and implementing a total hip replacement protocol. "What we did was identify key decision points that most orthopedic surgeons would be making when he does a total joint," says Secor. "For example, What type of preoperative blood do I need to get from the patient? Are there some special medical problems I need to address?’ Then we made an algorithm to flesh out those decision trees."
The decision-tree approach allows physicians greater latitude in customizing their own protocols, a factor that encouraged physician buy-in of the approach. It also allowed greater flexibility in tailoring treatment options to the needs of individual patients, Secor adds.
In general terms, the joint replacement protocol involves the following steps:
• Following a patient referral from a primary care physician, the orthopedic surgeon and MedSmart case managers perform patient assessment to determine if surgery is warranted.
• If the patient requires surgery, MedSmart case managers communicate information gathered in the assessment to hospital case managers. Surgery is scheduled.
• Following surgery, the patient is discharged to his or her home, or to an alternative care facility, depending on the patient’s clinical status. Discharge usually takes place within 48 hours if the surgery is conducted on an outpatient basis, and within 72 hours if it’s conducted in the acute care setting.
• Within a month of discharge, the patient attends 10 to 15 physical therapy sessions. Visits from nurses or home health aides are scheduled as needed. If the patient has been sent to an alternative care facility, case managers conduct a five-day follow-up assessment.
• The patient is scheduled for postoperative assessments at 30 days, three months, and one year. MedSmart uses information from these assessments in its final outcomes data process.
For Tufono, the biggest advantage of partnering with an outside case management company has been the opportunity to conduct more thorough preoperative patient assessments. "What happens is that you have a head start on what you’re planning for. With good preplanning, you can do things ahead of time to prepare for the patient’s coming into the hospital, and anticipate any needs they might have regarding equipment," she says.
MedSmart case managers also use the assessment to confirm the physician’s clinical choices to make sure surgery is necessary. To that end, they employ outcomes data research tools such as the SF36 and the Harris Hip Score. "When we start the data collection, we spend quite a bit of money," says Sue Sedaka, a case manager at MedSmart. "But even if we spend that money and come to the conclusion not to do the surgery, we’ve saved the patient and the payer a significant amount." (See cost breakdown, p. 74.)
MedSmart case managers conduct their patient assessments six weeks prior to surgery. They collect blood from the patient and list all coexisting morbidities, such as heart disease or diabetes. "If you plan for possible problems before surgery, things tend to go a lot smoother," says Secor. "And when they go smoother, you minimize the hospital stay."
The preoperative assessment also can affect the decision of whether to discharge the patient to an extended care facility or to home, says Secor. For example, during a recent assessment, case managers discovered that one of Secor’s patients kept 50 cats in her home. "Clearly, in that situation, the home environment is not going to be very clean, and might subject the patient to infection. So the decision was made early on to make sure that she wasn’t aggressively discharged to home, but was discharged to an extended care facility until the wound was completely healed."
Case managers also let patients and their family members know what to expect, both during the course of the hospital stay and afterward, says Secor. "When I did my analysis of what kept patients in the hospital, I found that a lot of it was anxiety, particularly about going home," he adds. "So we make sure that the extended family is available at the preoperative assessment so that they know what they need to do to support the patient in his or her recovery."
During the course of the patient’s hospital stay, Tufono’s contact with the outside company is minimal until the patient is ready to discharge. A home health case manager performs an assessment 48 hours before discharge and talks with Tufono about any necessary changes in the plan of care. "That facilitates their knowledge so that they can follow the patient to wherever he or she is dispositioned," says Tufono. "It’s a matter of ensuring that everything that has been planned is being taken care of."
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