Angie Roberson, RN, BSN, ACM Director of Case Management, SRHS E. G. Nick Ulmer, Jr., MD CPC VP Clinical Services and Medical Director of Case Management, SRHS
Two acute care facilities Spartanburg Medical 548 beds 30,000 discharges annually Level I Trauma Center 125,000 visits/year Emergency Center Level III Neonatal Intensive Care Only Recertified SC Magnet Hospital, #1 Robotics hospital in SC, first certified Chest Pain Center, first certified Stroke Center, Healthgrades #1 Cardiac Surgery Center in North/South Carolina Pelham Hospital 48 beds Long Term Acute Care Hospital Short term Skilled Nursing unit (SNF) Hospice Home Home Health Hospice
Case Management Governmental UR performed by RN s 7 day/week coverage ER coverage Commercial reviews submitted by small LPN staff Case Management assessment and discharge planning performed by a combination of RN s and Licensed Social Workers Support role using non licensed staff All reporting to one Director The SRHS Physician Advisor Team
Decided upon in 2010 due to climate External vendor use for three years prior Felt core physicians and a strong case management team could come together to manage cases and help devise internal efficiencies Wanted a culture change Team selection Transition process Go live 05/2011
7 days a week on call 7am-11pm each day 2 hour turn-around to assist CM with Status level determination LOS management Front line consultants and educators (real time) Meet with Dr. Ulmer every 4-6 weeks for Q/A, education on new information and team Serve as clinical administrative leads PAT member was selected to lead in OBS Unit start-up 3 PAT members serve as appeals from denials UM team members
Initial concurrent review- admission Critical elements All cases Timely Using Criteria Paper Electronic Referral to PA
Concurrent review - continued stay Based on initial review Observation- may review more than once in a day Inpatient- based on GMLOS of DRG Criteria Paper Electronic Capture avoidable delays/days Referrals to PA Coordination with other members of Case Management team
http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som 107ap_a_hospitals.pdf State Operations Manual Appendix A Revised 6-17-13 Interpretive guidelines Survey procedures
COP s mandate a UR plan The hospital must have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. Delineation of responsibilities and authority Establish procedures for review of medical necessity of admissions Appropriateness of setting Medical necessity of extended stays Medical necessity of professional services
COP s mandate a UR committee Composition of committee The determination that an admission is not medically necessary must involve the UR committee Including your PA s in the UR committee helps meet the requirement
http://www.pepperresources.org/ PEPPERresources.org is the official site for information, training and support related to the Program for Evaluating Payment Patterns Electronic Report (PEPPER). PEPPER provides provider-specific Medicare data statistics for discharges/services vulnerable to improper payments. PEPPER can support a hospital or facility s compliance efforts by identifying where it is an outlier for these risk areas. This data can help identify both potential overpayments as well as potential underpayments.
Benchmark against national, state and jurisdiction percentiles Report Data with a focus on admission necessity- TIA, COPD, PTCA 30 Day readmissions to same facility or elsewhere 3 day stay with transfer to SNF Top medical DRG s for 1 day stay Top surgical DRG s for 1 day stay Coding focus on over or under coding
Data is no good without Understanding what it means Being able to relate the data in understandable terms to colleagues PA role on UM team is huge in devising strategy for this Follow-up Did our strategy work? What do we make of the numbers now?
For SRHS, internal PA Peer to Attending is more amenable to change Attending education is real-time, based on case before them Documentation pearls Scripting: help me understand what you have here Internal PAs also see the dirt and can recommend a broom PA to PA: we use each other for wisdom of the room type dialogue Multidisciplinary team with PA as consultant to give guidance on case and serve as bridge to the attending with complex case discussion.
When the communication is working The right level of care is assigned to the right patient The patient care is delivered in an timely fashion and length of stay is reasonable The transitions at discharge go well The billing and denials headaches are manageable BUT.communication is HARD to achieve and maintain
UR Process design drives flow A few must haves. A well defined process An educated CM staff Data The support of Medical Director A robust Physician Advisor team and Communication Communication Communication
Nick Ulmer, MD CPC EUlmerMD@srhs.com Angie Roberson, RN, BSN, ACM aroberson@srhs.com Thank your for the opportunity to share our UR/PA process