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Outcomes Assessment and Quality Management Introduction The materials and information provided here are guidelines to be used to ensure the compliance with regulatory (Medicare and State) and Accreditation (Joint Commission Accreditation for Healthcare Organizations (JCAHO) and process improvement, especially with the Medicare CoP standards in section 482. 30 (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). The implementation of Utilization Management Plan is aimed to protect the Medicare beneficiaries rights, to improve quality of service and care, and to protect the integrity of the Medicare Trust Fund. Invasive procedure criteria, Severity of Illness and Intensity of Service (SI/IS) inpatient criteria should be used for screening cases for utilization issues in order to ensure that the patient received the necessary care within the appropriate setting. An effective Utilization Management Plan must: Acknowledge the nature of Utilization Management Plan and recognize the efficiencies that will be gained as the hospital improve their ability to use data and make necessary improvements in order to comply with Medicare Conditions of Participation (CoP) standards; Effectively use the information to define the patterns of utilization; Provide the co-operation and work with clinicians to define whether the variations and patterns are desirable or not; Work with clinically qualified personnel to implement necessary improvements; Ensure that clinicians integrate the utilization data into authority functions to implement effective strategic and local planning; Use all possible resources and infrastructure to ensure the appropriate utilization of resources and management, etc. Problem Statement A hospital located in Louisiana was recently surveyed by the State Department of Health using the Medicare Conditions of Participation (CoP) standards. Louisiana hospital represents one of the hospitals of a multi-system with more than 52 hospitals in 23 states and consists of a group of professionals who are engaged in both providing medical service and providing appropriate care within the medical service arena.
According to the results of survey conducted by the State Department of Health using the Medicare Conditions of Participation (CoP) standards, the hospital was found to be noncompliant with Medicare CoP 482. 30. Note: The Medicare CoP standards in section 482. 30 state that 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. As a result of non-compliance it was found out that the patients receive medical services that do not meet medical necessity creating over-utilization, under utilization, inefficient utilization of resources, and quality of care and liability problems. The Utilization Management Plan found to be not considered as a component of Performance Improvement with no defined performance indicators to measure the success of our utilization / case management program. The CMS Medicare Conditions of Participation (CoP) requirements are as follows: 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 (482. 30 Condition of Participation: Utilization Review); The Utilization Management Plan should provide for review for Medicare and Medicaid patients with respect to the medical necessity of: (i) Admissions to the institution (ii) The duration of stays; and (iii) Professional services furnished including drugs and biologicals The primary activities of Louisiana hospital leadership team, CEO, CFO, COO, CNO, and Quality Resource Management is to develop a written UR (Utilization Review) plan in order to be able to comply with Medicare Conditions of Participation (CoP) standards 482. 30. The Objectives: The main objectives of the Utilization Management Plan and Program are as follows: to provide the patients with medically necessary, high quality and efficient treatment, regardless of payment source and patients financial ability; to ensure that patients receive the right care at the right time in the right place; to ensure that pre-admission certification, concurrent review, discharge planning, case management, and outpatient certification are included; To examine all problem situations and to undertake the appropriate measures to eliminate the negative influences on hospital effectiveness Case Management Additionally, it was found out that not all Medicare and Medicaid patients were screened for medical necessity.
According to the Director of Louisiana Hospital, the underlying reason was in lack of staffing within the department. According to the national standards from the American Case Management Association (ACMA), a typical case load should be 1 case manager to 20 patients. Louisiana Hospital current staffing affords each case management a ratio of 1: 17. In result of interviews with the case management was found out that an overwhelming majority of the case managers doesnt understand their role and expectations. Moreover, no competencies have been identified and lack of formal education for case management was identified. The major part of case managers dont know such fact like patients stay is reimbursed on DRG, each having a defined length of stay, not to mention other cases.
The main aim is to undertake measures to assure that the patients received evidence based standards (medicine) and that the clinically qualified personnel are discharged accordingly monitoring for optimal patient stay. Possible Solution: To employ additional quantity of the case managers To implement explanatory courses for case managers in order to ensure they understand their role and expectations, namely to work with physicians to make sure the patients received evidence based standards (medicine) and that they are discharge accordingly monitoring for optimal patient stay, etc; To identify competencies and to provide the case management with additional formal education Education on Case Management and National Criteria Additionally, it was found out that the major part of clinically qualified personnel is not educated on case management and national criteria. The clinicians do not acknowledge the importance of the case management / utilization review program. Possible Solution: To implement physician education; Senior Leadership support and other explanatory programs / services /measures, etc; The Utilization Review Committee What concerns the Utilization Review Committee, it must carry out the Utilization Review function. A Utilization Review Committee should consist of two or more practitioners. Additionally, at least two of UR committee members must be Doctors of Medicine or Osteopathy (482. 30 (b) Standard: Composition of Utilization Review Committee).
The Louisiana Hospital UR committee doesnt have any practitioners to review outlier cases that do not meet medical necessity or exceed length of stay. Such situation doesnt comply with 482. 30 (b) Standard: Composition of Utilization Review Committee. Possible Solution: The Louisiana Hospital UR committee should undertake appropriate measures to ensure the compliance with 482. 30 (b) Standard: Composition of Utilization Review Committee. The management of Louisiana Hospital should employ two full time specialists and provide them with training on utilization and case management. The trained specialists will become the members of The Louisiana Hospital UR committee and will become the physician advisors to conduct peer review of those cases that no longer meet medical necessity.
Understanding Regulatory and Accreditation Components According to a thorough review of the case management department the director of the department was found to be an ineffective leader who didnt understand the regulatory and accreditation components. The manager of the department worked for the Louisiana hospital more than 32 years. Her experience in case management reaches 14 years. She has recently appointed the director of the case management department (namely, June 2006). According to the results of review, during her work as a manager of the department, the Length of Stay (LOS) has increased and the case mix index has decreased. Either she or the case managers werent effective in monitoring denials and avoidable days for adherence to national established criteria.
Possible Solution: In order to ensure the employees understand the importance of regulatory and accreditation components the management of Louisiana Hospital should appoint an appropriate person to replace the current director of the case management department. Expectations and Identification of the Customers Involved The expectations of the customers involved are to benefit from proactive medical screening. The hospital authorities are to ensure the patients receive the level of services appropriate to their medical condition and expectations. The physicians, therefore, are to be paid according to their adherence to evidenced-based medicine. Clinically qualified personnel are to set precedence on efficiency of professional services and quality of care in order to meet the expectations of the patients. Utilization Review Performance Measures and Measurement Tools A with any other UR functions, the Utilization Review plan will be evaluated on a regular basis in order to define the effectiveness in improving outcomes, managing care, facilitating access, and providing information for quality improvement, resource allocation and other management processes.
Taking into account success criteria, the UR plan has to protect the Medicare beneficiaries rights, improve quality of service and care, and protect the integrity of the Medicare Trust Fund. Invasive procedure criteria, Severity of Illness and Intensity of Service (SI/IS) inpatient criteria may also be used for screening cases for utilization issues in order to ensure that the patient receives the necessary care within the appropriate setting (i. e. , Long Term Care, Acute Medical, ICU, etc). The examples of measurement tools that will be used to identify and measure how effectively the Utilization Review decisions are implemented include: Hospital targeted DRGs and transfer DRGs; DRG analysis of actual versus targeted; Monitor quantity of cases; Average Length of Stay and Average charges on a monthly basis; Transfer DRGs quantity of patients discharged with a final transfer DRG assigned; Percentage of patients discharged with a final transfer DRG assigned; Quantity of patients with a LOS less than DRG GMLOS; Percentage of patients discharged with a LOS less than the DRG GMLOS; Quantity of times disposition incorrect and had to be changed after billing The examples of measurement tools that will be used to identify and measure how successfully the Documentation Improvement processes are established include the following indexes: Case Mix index (CMI) and Medicare DRG CC percentage; Variance / avoidable patient days: (reasons) facility; Medical staff; Discharge planning payer; Patient / family ; Inappropriate days in ICU; Other and total The examples of measurement tools that will be used to identify and measure how successfully the Denial management processes are established include the following indexes: Overall quantity of medical necessity denials; Approximate total $ denied; General quantity of appeals performed; General quantity of denials overturned; Approximate $ recovered The examples of measurement tools that will be used to identify and measure how effectively the completion of medical records is implemented include the following: General quantity of incomplete records > 30 days; Average monthly discharge (AMD); The percentage of delinquent records; General quantity of medical staff members suspended; Delay in services; Monitoring of case mix index and length of stays with detailed analysis Concurrent and Prospective Comparison As far as Louisiana Hospital is a part of a multi-hospital system of acute care inpatients, it will compare the results with the hospitals that are similar in size and services they provide to patients. Additionally, the Louisiana Hospital will use data from the American Case Management Association and Case Management Society of America website to assure that the hospital corresponds to national standards and incorporates all comparative information available.
The Louisiana Hospital will continue to collect applicable data with ongoing analysis and interpretation of the outcome data. The Utilization Review Plan foresees continuous collecting of qualitative and quantitative data aggregating and summarizing data for analysis. The comparative data will be used to measure the performance and interpret the information received in order to support the decision making processes. Problem Analysis The person who occupied the post of director for CM/UR is a long-term employee. The competence of CM/UR director is evident; however, her understanding of management principles is limited and ineffective. Additionally, a considerable part of the case management department is not aware of the role of case management.
The trainings and other educational programs on case management are mostly embrace the job training and interaction with other team members and CM/UR director. The inefficient training is considered the most possible problem that results in inefficiencies, ineffectiveness, and difficulty in prioritizing day to day workload activities, as well a potentially longer than necessary hours of work. Additionally, in result of recent reviews, clinically qualified personnel of Louisiana hospital feels lack in acknowledging of the importance of case management and appropriate utilization principles. The necessity in physician medical record documentation that will clarify medical necessity to support appropriate utilization is evident. Besides, the interim structure of Utilization Review Committee has no representatives from the Utilization Review staff. Possible Solutions The solutions, suggestions and alternatives are as follows: To revise the Utilization Review plan and to provide effective improvements in order to adhere to CMS Conditions of Participation; To ensure that corrected Utilization Review plan protects the Medicare Beneficiaries rights, improves quality of care and protects the integrity of the Medicare Trust Fund To examine the proposal to replace interim director of the case management department with an employee currently working in a PRN status due to a decision to delay filling the management position related to internal changes with the CNO position at our facility.
Possible candidate had officially applied for CM/UM director position. She has occupied the position of CM/UM manager UM in 2 prior for-profit settings, Mountain Health and Covenant Health. New director will undertake measures to reorganize the department in order to maximize efficiency and efficacy of the UR processes. She will recognize the necessity to reduce overall fees. Her plans embrace a potential reorganization that would incorporate CM/UM and discharge planning into the daily activities of each of the hospitals employees.
Implementing appropriate managing the patients during the week will allow eliminating the need for staff in-house on Sundays. Additionally, more appropriate direction with utilization in the Emergency Department will result in decreased LOS for patients admitted from the ED. Expectations and Possible Outcomes The benefit of solution is evident. The replacement of interim director by a person who has extensive knowledge and comprehension of the case management functions and responsibilities will strengthen the ability of Louisiana hospital to comply with the Medicare CoP. The effectiveness of UR processes will be increased. As far as Louisiana hospital UR plans main aim is to define the appropriateness of services and setting within which medical care is provided, it will provide valuable data taking into account the utilization of resources, definition of current levels of care (including alternative levels of care) and identification of current inefficiencies within a patient care unit / program or facility.
The quantity of clinically qualified employees will not increase. However, the proposal includes incorporation of flex staffing with the possibility of reducing 40 hour work week to 36 hours per case manager. The active participation of all members of the hospital in all working sessions and development an appropriate Utilization Management and Case Management Plan that will meet the Medicare CoP 482. 30 is expected among other outcomes of the UR program. The financial impact of UR program is obvious.
An implementation of effective UR program and usage of data collected from data analysis to identify and implement changes will improve the quality of care, treatment and services. The ability to effectively manage patients length of stay as well as efficient quality care services will be able to minimize the hospitals financial losses. Restructure of case management department will improve the quality of care, treatment and services. Potential Obstacles and Constraints The existing infrastructure of the Louisiana Hospital; Staff: possible resistance of the physicians to the utilization management and case management personnel; Intimidation by the case management staff working with physicians who are resistant; Learning curve for case managers to assume the role of utilization review / management and discharge planning Hospital priorities Standards (The team needs to develop the plan protecting the Medicare beneficiaries rights as a medical institution with existing practice) Possible Solutions and Strategies Possible solutions and strategies in order to overcome the barriers include: Education of senior leadership, physicians and case management staff; Routine monitoring of the program to ensure the processes that have been established are working; In case the processes are ineffective, defining and implementing of changes necessary for continuous performance monitoring and improvement should be done; Ensure ongoing improvement of UR management process.
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Research essay sample on Medicare Beneficiaries Qualified Personnel
