Care Management In Action: An Interprofessional Collaborative Practice Model Enhancing Patient Outcomes Hilary Joachim MAN, RN; Anita Milburn LICSW, MSW; Brenda Walsh MS, RN; Lisa Carter, MA, RN Mayo Clinic, Rochester, MN
A large Midwestern non-profit academic medical center recently transitioned RN Case Managers from the revenue desks to the patient bedside. RN Case Managers were partnered with Clinical Social Workers at the unit level to launch the Care Management model. The goal of the transition was to focus efforts on decreasing the observed to expected length of stay, evaluate ongoing medical necessity, and positively impact readmission and patient readiness to next level of care.
•
Discuss how the Care Management model has influenced readmission rates, avoidable delays and length of stay variance.
•
Recognize the advantages of interdisciplinary standard assessments on patient transition needs and mitigating barriers.
•
Summarize how the Care Management model has impacted interdisciplinary team dynamics and collaboration to positively impact patient experience.
Multiple initiatives took place over a one year time span starting in September 2017 to integrate the RN Case Manager into the interdisciplinary team.
Methods •
Electronic Case Management Tool (ECMT) utilized for documentation of stable to discharge date, progress of stable to discharge criteria, plan of care, delay and/or unnecessary hospital day documentation, and planned disposition, this transitioned to the new electronic health record (EHR) with implementation in May 2018
•
Length of Stay: Data Source – QMS (EPSi)
•
Number of Patients Discharged: Data Source – QMS (EPSi)
•
Number of Patient Days: Data Source – QMS (EPSi)
Implementation of shared standard assessments and early interventions for every patient
•
Readmission Rate: Data Source – QMS (EPSi)
•
Extent Felt Ready to Discharge: Data Source – Press Ganey.
•
Education to key stakeholders about the model
•
Speed of Discharge: Data Source – Press Ganey
•
Enhancement of interdisciplinary collaboration
•
Overall Rating: Data Source – Press Ganey
•
RN Case Manager attendance at charge nurse huddle
•
Press Ganey – Uses Top Box Methodology
•
Early morning huddle on patients discharging that day
•
Midmorning interdisciplinary rounds on all patients, with focus on key discharge criteria
•
Afternoon touch-point between providers and Care Management to close the loop on all patient needs
•
Care Management team touch-points three times daily
•
“Critical to Follow” daily rounds to troubleshoot delays
Model Foundations Foundational initiatives for this model included: •
•
A unit-based Care Management team which united the clinical skills of the RN Case Manager and the psychosocial skills of the Clinical Social Worker
Patient Experience Outcomes
Objectives
Background
Implications
Data/Results •
Improvement can be seen in Patient Satisfaction in relation to Extent Felt Ready to Discharge and Speed of Discharge with the unit outperforming the Press Ganey Top Box score for these metrics in 5 of 5 quarters and 4 of 5 quarters respectively (Graph 1).
•
Readmission rate has had downward trend since implementation of Care Management on the unit in May 2017.
•
Average Length of Stay (ALOS) has remained stable in comparison to the Geometric Length of stay (GMLOS) with minimal change in the Case Mix Index (CMI).
•
Reasons contributing to internal discharge delays has reduced.
Next Steps
Conclusions Implementation of the Care Management model within the medical specialty has: •
•
Improved patient satisfaction measures in relation do discharge
•
Controllable internal hospital factors contribute to delays in care and discharge have reduced
• Newman, James S. (2018). The heart of the hospital. Mayo Clinic Proceedings, 93(11), 1549-1551.
Improved collaboration by all members of the interdisciplinary team at daily rounds, huddles, and touch-points has enhanced quality conversations focused on essential discharge elements and early discharge planning
Increased transparency of metrics and coordination of patient needs
•
Dissemination of Care Management model across all inpatient care units.
•
Identify ongoing educational needs for Care Management team to further develop, enhance and standardize practice.
•
Continue to monitor data to inform and guide practice, education and research.
•
Identify additional metrics that are representative of the Care Management model.
•
Reinforce education with interdisciplinary team on medical necessity and insurance implications. © 2017 Mayo Foundation for Medical Education and Research