© 2013 MCG. All Rights Reserved. CREATING A 24/7 UTILIZATION REVIEW PROGRAM IN A CRITICAL ACCESS HOSPITAL Sandra Clarke, RN, BSN (Medical/Surgical Director) Jessica Faude, RN-BC (Discharge Planner) Moderator (MCG) A Small Town Success Story Presenters (Memorial Health Center) Jeremy Rittierodt, MSN, RN, CCM, CTT+

2© 2013 MCG. All Rights Reserved. The Big Picture: Rural Health The challenges were: Competition from larger bed/higher acuity facilities Attracting patients who are established at larger facilities Attracting and retaining providers Limited resources Constant battle against thin financial margins

3© 2013 MCG. All Rights Reserved. The Big Picture: Rural Health (continued) The Advantages Personalized care: We know our patients Smoother transitions for change –Ideas easily escalated to senior leadership –Can make changes quickly

4© 2013 MCG. All Rights Reserved. Memorial Health Center Level III trauma care and Critical Access Hospital in northern Wisconsin Celebrated 50 years of service in 2012 Partnered with Aspirus, Inc in 2001 Embarked on Journey of Excellence in 2008

5© 2013 MCG. All Rights Reserved. Memorial Health Center (continued) Not-for-profit, Primary Care Hospital 5 Primary Clinics Specialty Clinics Pharmacy Therapy Centers Public Fitness Center Skilled Nursing Facility Swing Bed Program Assisted Living Facility Senior Income Eligible Apartments

6© 2013 MCG. All Rights Reserved. Memorial Health Center: Challenges Effects and causes Inaccurate status determinations Patient dissatisfaction: Delays, financial impact of inaccurate status determinations Staff stressed: Monday & early morning UR backlog, struggling with medical necessity and required documentation Providers frustrated: Poor coordination, lack of structured process 30-day readmissions at 9.1% Financial challenges: Reimbursement rates

7© 2013 MCG. All Rights Reserved. Criteria for a Potential Solution Needed a program that would impact: Patient care and safety Patient, provider, and staff satisfaction Financial standing Chose Web-based acute care guidelines from MCG: Inpatient & Surgical Care General Recovery Care

8© 2013 MCG. All Rights Reserved. Pre-Development Steps Early buy-in from senior leadership Began trial process in May 2011: UR RN notified of all admissions during office hours Began to manually track inappropriate admissions, inappropriate status, and changed status Trialed a binder with common care guidelines for ED physicians

9© 2013 MCG. All Rights Reserved. Planning Stage Needed an improved process to cover 24/7 utilization review Developed a policy and procedure defining process Utilization Review Committee approval Education provided to ED committee and medical staff and subsequent approval of new process Education provided to departments and staff

10© 2013 MCG. All Rights Reserved. Potential Obstacles: Budget & Staffing Smart phones with 24/7 access to the care guidelines On call compensation Physician advisor role Lesson Early buy-in from senior leadership pays off

11© 2013 MCG. All Rights Reserved. Implementation 24/7 utilization review program initiated (September 19, 2011) 1.UR nurse contacted (all admissions) 2.UR nurse determines appropriate admission status using care guidelines that can be accessed on the smart phone

12© 2013 MCG. All Rights Reserved. Implementation (continued) 3.Admitting provider and UR/charge nurse sign MHC Utilization Review Admission Determination with appropriate status checked 4.Relevant care guideline printed and placed – with criteria highlighted – in medical chart under Physician Orders 5.Daily review documentation and notes written directly on printed guideline

13© 2013 MCG. All Rights Reserved. Outcomes: Before and After Remember those challenges? Inaccurate status determinations –More accurate admissions –30-day readmission rate reduced from 9.1% to 5.6% –Quality Measure benchmarking Patient dissatisfaction –Patient satisfaction scores rose sharply

14© 2013 MCG. All Rights Reserved. Outcomes: Before and After Remember those challenges? Inaccurate status determinations –More accurate admissions –30-day readmission rate reduced from 9.1% to 5.6% –Quality Measure benchmarking Patient dissatisfaction –Patient satisfaction scores rose sharply

15© 2013 MCG. All Rights Reserved. Outcomes: Before and After (continued) Remember those challenges? Staff stressed –Smart phones support flexible hours, happier UR nurses –Increased sense of teamwork –Time savings across departments (medical records, registration, coding, billing) Providers frustrated –Greater sense of trust among providers –Proactive referrals for therapies, skilled nursing facility placements or home health during the admission process Financial challenges –Billable observation hour reimbursement increased $226,666 or 64%

16© 2013 MCG. All Rights Reserved. Outcomes: Before and After (continued) Remember those challenges? Staff stressed –Smart phones support flexible hours, satisfied UR nurses –Increased sense of teamwork –Time savings across departments (medical records, registration, coding, billing) Providers frustrated –Greater sense of trust among providers –Proactive referrals for therapies, skilled nursing facility placements or home health during the admission process Financial challenges –Billable observation hour reimbursement increased $226,666 or 64%

17© 2013 MCG. All Rights Reserved. Driving Effective Care Evidence-based guideline at providers fingertips for all admissions Documentation winsCare plan preparation Faster insurance and clinical reviews Overall, streamlined process from admission to discharge

18© 2013 MCG. All Rights Reserved. Questions? Please contact us. Jessica Faude, RN-BC Sandra Clarke, RN, BSN Jeremy Rittierodt, MSN, RN, CCM, CTT+ Memorial Health Center MCG Doyle Award careguidelines.com/content/doyle-awardcareguidelines.com/content/doyle-award