*Explain strategies that support utilization management in a health care setting.

Transcription

1 Deborah Cutts, Chief Quality Officer 1 Chris Rovinski-Wagner, Coach Captain Discuss utilization management in the context of variation in health care delivery. Explain strategies that support utilization management in a health care setting. 2 1

2 Appropriate use of beds in-line with Inter-Qual criteria provides the most cost effective use of healthcare dollars. Continued stays which do not meet InterQual Criteria add to inappropriate costs associated with diversion. During 4th Q FY2011, it was estimated that WRJ VAMC expensed approximately $1.4 million (24 Veteran patients) who were diverted due to lack of bed availability. This is based on a conservative average of about $60,000 per Veteran patient. 3 Physicians: Acute Inpatient Hospitalists, Inpatient Psychiatry, Chief of Medicine, Chief of Staff Nurses: In-patient Case Managers, Utilization Management Social Workers: In-patient Med/Surg, In-patient Psychiatry Business Office Leadership Quality Management: Chief Quality Officer, Improvement Advisor Sponsor: Chief of Staff 4 2

3 Increase the percent of inpatient continued stay bed days of care that meet Inter-Qual Criteria from the baseline 47% (May 8, 2012) to 72% by September 30, Reduce the cost of inappropriate bed days of care 12% from $2,428, as of March 30, 2012 to $2,137, by September 30,

4 WRJ VA Continued Stay Current State Process Map June % White River Jct. Continued Stays Meeting Criteria June June % % 100 Goal 72% 80 60% 60 40% 40 20% 20 0% 6/15 6/22 6/29 7/6 7/13 7/20 7/27 8/3 8/10 8/17 8/24 8/31 9/7 9/14 9/21 9/30 10/7 10/14 10/21 10/28 11/4 11/11 11/18 11/25 12/2 12/9 12/16 12/23 12/30 1/6 1/13 1/20 1/27 2/3 2/10 2/17 2/24 3/3 3/10 3/17 3/24 3/31 4/7 4/14 4/21 4/28 5/5 5/12 5/19 5/26 6/2 6/9 6/16 0 Med - # Reviews Psych - # Reviews Surg - # Reviews 405 Goal - 72% Linear (405) 8 4

5 Why would the Business Office be involved in a continued stay discussion? Date Event Brief explanation $ Saved Patient unable to be transferred to non-va institution post acute care due to lack of available transportation. Potential increase in LOS = 2 weeks conservatively. Business Office confirmed secondary eligibility thru 9-Jul-12 Transportation obstacle to discharge. local facility travel. Patient discharged without having not-met continued stay days. $13, COMPLETED Move ECT & Opt Detox patients to the new Residential Rehab / Lodge Building once acute care no longer needed Use of current Lodge beds for ECT patients (as appropriate) pending opening of new lodge Building Address real vs. perceived need for Guardianship and include legal counsel in local process Engage in case review for / when requests for admission to Manchester VA alternate level of care (Community living Center) are made Since beginning g of FY13, saved approximately $40,000 by transferring patients to RRPT once acute care no longer needed. 10 5

6 CONTINUING Engage in dedicated discussion regarding nursing documentation, i.e., charting to the negative vs. the positive Discuss physician documentation, i.e. charting to the negative vs. the positive as it relates to potential medical-legal and or placement difficulty implications Participation in the VA VISN 1 Bed Huddle Pilot. An Unexpected Return-on-Investment In 2012, 56% of medical students and residents reported satisfaction with activities related to Preparation for Business aspects of Clinical Practice We are watching as our residents evolve into excellent providers of healthcare as well as committed stewards of healthcare resources. 11 Real-time not-met feedback to PUMAs (psych, surgery and medicine) once per week (on the day each wants to receive it and for the period they want to review) Patient Name SSN Unit Admit D/C Treating Date Date Specialty Admitting Diagnosis Attending Physician Date Being Rev Crit Reas Reviewed Type Met? Code ALOC 12 6

7 30-minute huddles 3 times a week with four in-patient medicine teams to discuss patients who are not meeting continued stay criteria AND those who it is anticipated will not be meeting. Huddle notes shared on a folder in the common drive. 13 In-Process Surgical Service / Primary Care collaborative pilot for reducing total joint LOS (initiated May 2013) Pursue activation of NUMI software functionality which would allow real time / instant provider notification when their patient does NOT meet Deploy utilization management program to the ED / Admissions level (Plan to initiate December 2013) 14 7

8 15 Monthly reports to Senior Administrative and Clinical Leadership Sharing during VA VISN 1 Bed Huddle calls Weekly reports to clinical service chiefs Sharing with our colleagues in the UM Community and other collaborative venues 16 8

9 120% 100% White River Jct. Continued Stays Meeting Criteria % 60% 40% 20% 0% Goal 72% Med - # Reviews Psych - # Reviews Surg - # Reviews 405 Goal - 72% Linear (405) We re tanking!!!! What happened????? We did a gap analysis. 17 What do You Want to Change? Why do You Want to Change? Present How are things now? Describe the same components in the future state, only do so in real, present terms. Again, be very detailed. Gap "What is keeping us from the future? What are the barriers? What are the missing components? What actions do we need to take to reach the future?" Future Where you/the group wants to be at a specific time. The description of the future must be detailed. What Actions are Needed to Move from Present to Future State? in other words strategic improvement versus organizational culture 18 9

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11 Thank you for allowing us to share our patient flow experience with you