Patient Flow E-Newsletter
Volume 3, Issue 3
Wednesday, October 25, 2006
It's easy to understand how care managers are one of the busiest groups of hospital-based employees in today's health care system. Care managers must stay on top of doctors' discharge recommendations, guide patients through the discharge process seamlessly, and explain a patient's post-hospital options - all while navigating private and public insurance plans to ensure payment.
As health care leaders understand more about how hospital-wide discharge processes affect crowding in the emergency department (ED), many hospital leaders are counting on care managers to be even more efficient.
The Albert Einstein Medical Center in the heart of Philadelphia is a case in point. Like many urban hospitals, it has a very busy emergency department, with an average of 200 patients coming through the ED doors each day - a significant increase in a short period of time. Although the ED was redesigned in January 2005 to add 28 new beds, the hospital continued to struggle with the increased volume.
Getting An Outsiders' Perspective
Two years ago hospital leaders enlisted Cap Gemini to conduct a full assessment and implementation plan for how the hospital could better manage its patient flow. It was one of the few times the organization used outside consultants to analyze and implement operational changes.
"Sometimes an unbiased, outside group can see things that insiders cannot. For us, having an outsider's perspective was extremely helpful" said Cindy McGlone, vice president of Health Care Services at Albert Einstein.
The analysis by Cap Gemini demonstrated that two of the hospital's greatest challenges were prolonged length of stay (5.5 days, on average) and frequent ambulance diversion (an average of 200 hours per month), both of which were negatively impacting the hospital's finances. For every two hours Albert Einstein spent on diversion, it was losing one patient admission.
The challenge was clear: free up space by discharging eligible patients in a faster, more efficient fashion. With overwhelming support from the President/CEO and COO of the Albert Einstein Healthcare Network, changes began to take place immediately. A multi-disciplinary Work Group was established with McGlone as its leader. The Work Group began implementing recommended changes including:
- Using a sophisticated bed-tracking system that registers when a bed is ready to be cleaned or becomes available for a patient;
- Utilizing a new software system that facilitates the placement of discharged patients in nursing homes;
- Implementing weekly rounds for patients who have been hospitalized for 10+ days to discuss their long-term care plan; and other ideas.
An Overhaul of the Care Management Department
As part of its analysis, Cap Gemini recommended that a care manager should be responsible for no more than 25 patients, but Albert Einstein's care managers usually had patient loads of 30 or greater - managing everything from calls to payers, to setting up home care, to making referrals to nursing homes, and more. Although several changes were implemented, all agree that one of the most beneficial changes was streamlining communications with payers.
"On any given day, a care manager was sometimes calling four different insurers that we have in the Philadelphia area. A colleague may be calling all of them as well. Most care managers were calling at least two or three insurers on a daily basis. We realized that this could be done much more efficiently," said McGlone.
The Work Group redesigned the Care Management Department by establishing a Resource Center to support care managers. Rather than having several different care managers each calling multiple payers regarding half-dozen or more patients, one person is now assigned to each major payer, and that person makes all calls. Not only has this proven to be a more efficient use of time and resources, it had the added benefit of Resource Center employees building relationships with the payers.
'Speed Dating' Rounds
One of the hospital's most intriguing changes to the Care Management Department was to adapt a lesson learned from a contemporary approach to meeting that 'someone special.'
"The whole concept of speed-dating, where a group of singles get together for an hour and hold a succession of five-minute mini-dates by rotating around the room from chair to chair, had just caught on in the Philadelphia area last year. We had the idea of doing discharge rounds in the style of speed dating," said McGlone.
Instead of care managers doing rounds all over the hospital, the team set up the Care Management office suite for speed dating-style rounds. One room represents the fourth floor; the next represents the fifth floor; etc. Care managers and social workers each sit in the room assigned to their floor and wait for the residents to come to them. It is also convenient for residents, who simply move from one room to the next, meeting with a series of care managers rather than running from floor to floor throughout the hospital.
Going Paperless
Before Cap Gemini was engaged, nearly everything in Albert Einstein's Care Management Department was recorded on paper. Not only were care managers loaded down with huge binders of patient information that they carried throughout the hospital, but it was difficult to locate information after the patient's discharge. Now when care managers conduct patient evaluations, they enter the data in the hospital's newly purchased software system, which anyone can then look up at any time.
Care Managers in the ED
As insurers' restrictions have tightened on which patients can and cannot be admitted, hospitals nationwide have begun to establish care managers in their EDs. Because they had seen it work well at similar institutions, the Capgemini team recommended this approach for Albert Einstein.
"One of the biggest benefits is that ED care managers help make sure that anyone being admitted meets InterQual criteria, the criteria that determine medical necessity. Since instituting this, we have decreased the percentage of ED arrivals who are admitted," said McGlone. "We are now better at identifying people who do not meet InterQual criteria - meaning that they need care, but may not need to receive that care in a hospital setting."
McGlone thinks the changes at Albert Einstein have raised the bar on expectations. It shows. In the latest monthly tabulation, Albert Einstein was on diversion for an average of only seven hours per month - compared to an average of 170 hours per month just two years ago. The changes have also helped shave four-tenths from the hospital's average length of stay, from 5.4 days two years ago to just 5.0 days today. Click here to view the Performance Indicators Table.
As for advice to any hospital thinking about adopting Albert Einstein's changes, McGlone said, "You need to be willing to listen to outside experts and determine ways to adapt their recommendations to your needs. Many times the ideas will work really well. Sometimes they may not, but that doesn't mean that you give up. Just try something else. Every idea leads to new ideas."
