PHOENIX MEDICAL MANAGEMENT, INC.

On July 22, Phoenix sponsored it's first conference call with over 28 hospital case management leaders joining in.  The topic is a timely one as hospitals try to adapt to new demands in the coming years and case management leaders explore new opportunities to provide essential services.

The Agenda for the one-hour conference call provided a structured approach to address some of the issues surrounding the topic:

1.  Model definition. 

Moderator Stefani Daniels made sure that everyone was on the same page with regard to a single definition of the UR function:  A chart review activity to compare medical documentation against nationally recognized acute care criteria to confirm patient level of care.  Once everyone accepted the definition, Ms. Daniels went on to explain that there are two traditional UR requirements.  The first is the federally mandated requirement as stated in the Conditions of Participation (CoP)and applicable to all regular Medicare and Medicaid patients.  The second is the contractual obligation entered into between the hospital and the insurance company.  In both situations, the traditional retrospective chart review task is conducted either pre-admission, at admission or after admission.  A second level review is then performed at some point during the LOS based on the contractual requirements for commercial patients or each hospital's UR plan for M & M patients.  The model therefore, separates the UR chart review function from CM practice.

2.  Intent . 

To fully understand the intent of separating the UR function from CM practice, it would be helpful to review the evolution of hospital case management programs.  In the beginning there was clinical case management models which originated at the New England Medical Center and the pioneering work of Karen Zander.  Hospitals took a hard financial hit after the introduction of the DRG reimbursement system and many did not survive. Those that did looked to reduce costs quickly and found opportunities in creating case management departments.  However, rather than building on the clinical model, consultants re-engineered departments to combine activities and reduce FTEs. As a result, UR departments and SW departments were collapsed into case management departments with no clear understanding of what constituted case management practice.  This signaled phase 2 of the evolution of hospital case management (HCM) which we call functional models of case management practice and they continue to dominate the landscape.  There are many variations, but UR and DCP tasks are the primary intent of those models. 

Neither the ACMA nor CMSA define CM practice in terms of tasks.  Both professional organizations speak of a process of assessing, coordinating, collaborating, implementing, evaluating, and advocating.  We refer to this process as progression-of-care.  If HCMs are expected to proactively participate in the progression of care, then the question has to be asked, "when is there sufficient time to review charts for UR?"  The intent of separating the UR function is to relieve the HCM of the burden of conducting retrospective chart reveiws and instead position him or her at the side of the physician, the nurse, the patient, the family, PT, pharmacist, et all, in order to 'manage' progression-of-care.  Separating the UR function therefore, leaves the HCM to practice case management as defined by our professional associations and as historically based.

3.  Skill Mix. 

When this issue is raised in the C-suite, the question always arises about who is best suited to do these chart review activities.  Generally, comparing medical record documentation against specific criteria in a book or an electronic platform, does not require a licensed professional.  Once again, remember we're speaking about the traditional UR function as defined above.  It does require someone with knowledge of medical terminology and who is familar with medical records.  We have seen very successful UR specialists who are LPNs, medical assistants, nursing students, or savvy clerical assistants.

Two related issues were addressed: 

    A. UR specialists are especially valuable performing initial reviews but are they best positioned to ensure appropriate LoC determination past the first 3 - 4 days?  It depends!  If the UR specialist is assigned to commercial payers then the contract will determine the frequency of formal reviews.  In this scenario, we believe the UR specialist may be best suited for that task.  But what about regular M & M patients?  Are formal reviews necessary every 3 days?  Well, that too, depends. Only this time it depends upon the hospital's UR plan.  Remember, the CoP provides guidance on WHAT the hospital must do but the UR plan defines HOW it is to be done at your facility.  If your plan states that a formal review must be performed at the trim point, then, yes, perhaps it's best that a UR specialist conduct that review for intensity of services  (SI & IS at admission, but IS and discharge screens for continuing stay). If however, your UR plan states that the patient's need for continuing acute LOC will be determined periodically through consultation with the physician and members of the clinical team, then perhaps the HCM can take that responsibility on as part of the progression-of-care management without performing a formal chart review.

    B.  The second related issue pertains to advocacy.  Every HCM is obligated to ensure that the patient's immediate acute care are addressed....nothing less and certainly, nothing more.  Nothing more because 'more' can add potential risk to the patient's stay.  If medical interventions are not appropriate for numerous reasons, then the HCM is obligated to speak up to try to influence the outcome.  Therefore, to effectively practice advocacy and ensure the patient receives treatment, services or supplies that are appropriate to his immediate needs, the HCM must be knowledgeable about clinical resource management, level of care criteria, evidence based protocols and the treatment plan.   Don't confuse clinical resource management with UR.  UR is a retrospective activity of reviewing medical documentation to ensure compliance with pre-determined acute care criteria.  Resource management is a prospective activity to prevent an unwanted event from occurring in the first place.

4.  Communication Linkages. 

Any model that separates the UR function from the practice of HCM has to ensure that there is good communication between the UR specialist and the HCM. That communication might be a product of the infrastructure of the department.  Large hospitals often have teams dedicated to specific patient populations. That team may be comprised of an HCM and a UR specialist; an HCM, a UR specialist or a SW; an HCM, a UR specialist and a post acute coordinator or may or may not be a SW; or any combination of these roles.  The infrastructure makes it easy for each role to stay in touch with the other.

In smaller hospitals, strategies may have to be designed to share information. Whether regular 'huddles' or scheduled rounds, some consistent mechanism is essential to give and take information which the UR specialist needs to do her work and the HCM needs to keep the progression-of-care moving forward.

5.  Benefits.

* Consistent resource to support patient navigation.

* Shift in priorities from chart review to physician partnerships to manage progressiion-of-care.

* Change in workflow activities to incorporate progression-of-care activities such as accompanying physicians on rounds, intepreting physician recommendations, and preparing patient for discharge.

6.  Challenges.

*  Incumbent HCMs may not be prepared to co-manage progression-of-care.

*  Mistrust that UR activity will be "done right".

*  Communication gaps.

*  Separate administrative report structure compromising lateral communication.

*  Transforming structure within a set budget.

*  HCM 'traditions' and reluctance to accept change.