Enough is Enough! Something is Wrong! A System Wide Utilization Management Rapid Improvement Workshop Spurred a Hospital Wide Performance Improvement Project Kimberly Brady RN, BSN, HCA, and Megan McClure, LMSW Learning Objectives Identify how to initiate a system wide approach to apply medical necessity Determine how to engage physicians to change culture around Utilization Management Implement real time monitoring score card to assess observation status
Background Throughout 2017, there were several internal discussions at UHS regarding a number of critical challenges including an increase in observation cases, denials, observation length of stay, and patient dissatisfaction due to an inability to meet the three midnight rule for a skilled nursing facility stay. Several internally driven initiatives were developed to address these challenges, but each ultimately failed to produce impactful results. We quickly realized that we needed outside assistance. We decided to engage Clinical Intelligence (CI), a national care management consultancy and analytic firm with whom we had a long standing relationship through other performance improvement projects. CI provided us with an analytic platform to analyze our financial, quality and care management metrics. It was decided CI would come on site for a three day Utilization Management rapid improvement workshop in March 2018. The focus was on the Utilization Management processes and practices at all ports of entry. In interviewing the medical staff, it was clear many were placing patients in observation because they wanted to prevent a concurrent denial and having to perform a peer-to-peer review. Simply, they were defaulting to observation. The three-day workshop resulted in a 114-item action plan in the following six categories:
Medical Necessity
Results
A patient must meet medical necessity to be assigned an inpatient status. The decision to admit a patient is a complex medical judgement which can be made only after the physician has considered a number of factors:
Observation Rate
The elements needed for Medical Necessity are: Severity of Illness (How sick is the patient)? Clinical indications of illness using primary diagnosis and comorbid conditions, clinical imaging, labs and documentation in the medical record too sick to be treated in the outpatient setting
5. Care Coordination 6. Denial and Appeal Management Additionally, during this time 40 observation charts were reviewed that had a length of stay greater than two midnights. We identified 18 charts, which translates to 45%, met medical necessity for inpatient in the Emergency Department. One of the charts we reviewed was an 89-year-old patient that was in observation for 5 days. This patient was a readmission within two weeks and the patient expired. The team considered if the patient had been allowed to utilize their skilled nursing benefit and been in a supervised setting the patient may have had had a different outcome.
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• Daily and monthly dashboards to monitor observation performance • Root cause analysis on patients staying greater than 48 hours in observation
• Decrease in Observation Cases • Creation of a new Outpatient in a Bed (OPIB) status • Revitalization of the Utilization Management Committee with medical staff
Likelihood of an adverse outcome
• Decreased Denials • Decrease number of observation cases that stayed greater than 3 days
Top Three Priorities 1. Implement a system-wide training of applying medical necessity education 2. Improve the Emergency Department’s ability to determine the correct status, Outpatient Observation vs Inpatient, the first time 3. Design a denial management strategy
Goal Apply medical necessity for inpatient appropriately from the point of entry to ensure patients benefits are not compromised.
2. Bed Access Management 4. Utilization Management and Physician Advisor
• A culture was created to allow physicians to be physicians but encouraging them to use their medical judgement and not as much about payers during their decision making
• Improved partnership between Care Management and Finance
Intensity of Service (Can this treatment be provided at a lower level facility?) Address risk of mortality, likelihood of death if not treated in the hospital
1. Care Management structure 3. Observation Management
The Rapid Improvement Workshop started in March 2018. There were some just do it items that were initiated in March and an action plan was developed with 114 items that spanned the whole organization. The nurse care manager education was completed mid April. Physician education started in April 2018 and was completed by June 1st 2018.
Outcomes
Daily Scorecard
Lessons Learned
The jump up in observation rate in December 2018 and January 2019 is contributed to the start of flu season and an increase in respiratory symptoms. Denial Management
Prior to the Utilization Management Rapid Improvement project, the medical necessity denied claims specialist were appealing about 50% of denials with a success rate of about 50%. Currently the team is appealing approximately 85% of the denials and has a win rate of approximately 80%. The team utilizes an outside vendor for appeal management, R1, when the volume of denials is high. This success is due to the education provided to the physicians, care management team and denied claims specialists.
• Interqual or Millman are evidence based nationally accepted guidelines for medical necessity. These guidelines were written to be applied by nurses. The evidence guidelines are used to compare physician documentation, test results and plans against nationally accepted criteria. However, not every patient will fit into the criteria. It is import that the physician’s documentation in the History & Physical outlines the severity of illness, intensity of service and likelihood of an adverse event. • It is important to have a physician advisor program to support the utilization management and care management department. • Providing education in person regarding medical necessity had more of an impact compared to sending out power point education. Education needs to be reinforced regularly. • The Utilization Management team can be used to drive quality improvement with proper physician engagement.
Acknowledgements • Physician advisor and champion for this project, Dr. Jeffery Gray. • Physician advisor Dr. Shahid Mughal. • Clinical Intelligence, consultant group. With a special thank you to consultant Maureen Murphy RN, BSN, MBA, ACM. • The best Care Management Staff that always does what is right for the patient. • Revenue Cycle staff for helping to break down the silos to improve processes and communication.