Design an inner-hospital early warning system
Design an inner-hospital early warning system
By Patrice L. Spath, ART, BA
Consultant in Health Care Quality and Resource Management
Forest Grove, OR
With today’s shortened hospital lengths of stay, inpatient case managers must quickly identify those patients requiring clinical, social, and financial interventions. For this reason, it is important to integrate case management screening into the hospital admission process. For example, case managers should receive referrals regarding emergency admit patients within a few minutes of the patient’s arrival.
For elective admissions, case managers can initiate services even before the patient comes into the hospital. Implementing a hospital case management screening process involves two steps. First, a definition of case management referral triggers must be established. Second, a screening process must be designed. Ideally, this process is designed with the input of all members of the health care team, including physicians and medical office staff.
Case management referral triggers
The referral triggers for case managers can be disease or condition specific. Many diseases and conditions, both acute and chronic, have the potential for case management. Some examples are:
• accidents/injuries;
• AIDS and positive HIV status;
• cancer;
• neuromuscular diseases/disorders, such as muscular dystrophy;
• blood disorders;
• diabetes with frequent hospitalizations;
• endocrine/metabolic disorders, such as hypopituitarism;
• cardiac disorders;
• pulmonary diseases;
• renal failure;
• congenital disorders/birth defects.
When patients present with one or more of these conditions, an automatic case management referral may be initiated. If clinical paths exist for one or more of these conditions, case managers may be alerted to the patient’s admission but are not primarily responsible for their case management needs. In many hospitals, the bedside nurse serves as the patient’s primary case manager when a pathway is available to guide decision-making.
Another screening technique is to identify patients with psychosocial problems or situational issues which require more in-depth assessment and treatment planning, regardless of their clinical diagnosis. These ’red flag” problems might include limitations in the patient’s ability to perform activities of daily living (ADL), financial factors, mental status, or special care needs.
The most comprehensive approach is a combination of disease-specific and red flag screening tools to ensure that all patients needing case management are identified.
Design a screening process
The personnel responsible for completing the screening assessment vary among organizations. Ideally, the first health care professional who interacts with the patient should initiate the screening process. For emergency admissions, this may be the emergency department staff or admitting personnel. For elective admissions, this may be the medical office staff, surgery scheduling staff, or admitting personnel.
When designing your approach, bring together these different professionals to discuss the best strategy for quickly identifying patients needing case management services. Using process improvement techniques, ask the team to map out the current admission process and identify points where screening can take place.
Tools for screening patients should be designed with the users in mind. Admitting personnel, for example, may not have the clinical expertise necessary to judge a patient’s ADL status. Admitting personnel might, however, be able to identify financial or living arrangement red flags.
Physician’s staff can help
Don’t overlook the proficiency of physicians’ office staffs. They may have considerable knowledge about a patient’s social and clinical conditions and can easily communicate this information to the hospital case managers.
Build into the admission process screening tools that can be completed by staff who with varying levels of expertise and/or special knowledge of patients’ requirements. Obtain general information from the physician’s office staff by interviewing the patient. Patient interviews can be conducted by physician office staff when a surgery is scheduled. The information then can be forwarded to the hospital case management office.
Where deemed necessary, case managers can contact patients before their arrival to clarify any post-hospital care requirements and ensure that necessary services are available immediately upon their discharge.
Gather info at admission
Hospital staff can obtain different medical history information, however, during a patient’s admission or when they gather pre-admission information. The pre-admission tool is useful for scheduled and emergency admissions. Admitting personnel are responsible for completing the first portion of the assessment, and the admitting nurse is responsible for the clinical portion.
The admission screening tool should be maintained as a permanent medical record document, and an NCR copy should be forwarded to case management. The information provided on the form helps the case managers identify patients requiring intervention and minimizes the risk of duplicate referrals to support departments.
A hospital’s case management procedure commonly states that all patients will be assessed for their case management needs within 24 to 48 hours of admission. The average length of a hospital stay, however, has dropped below six days in most regions, making it difficult to complete assessments and initiate appropriate interventions without more timely problem identification.
Analyzing your current patient admission process and bringing together all involved staff to discuss screening alternatives will allow you to better meet the needs of today’s short-stay hospital patient.
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