We think you have liked this presentation. If you wish to download it, please recommend it to your friends in any social system. Share buttons are a little bit lower. Thank you!
Presentation is loading. Please wait.
Published byRaegan Cristy
Modified over 2 years ago
© 2013 MCG. All Rights Reserved. CREATING A 24/7 UTILIZATION REVIEW PROGRAM IN A CRITICAL ACCESS HOSPITAL Sandra Clarke, RN, BSN (Medical/Surgical Director) Jessica Faude, RN-BC (Discharge Planner) Moderator (MCG) A Small Town Success Story Presenters (Memorial Health Center) Jeremy Rittierodt, MSN, RN, CCM, CTT+
2© 2013 MCG. All Rights Reserved. The Big Picture: Rural Health The challenges were: Competition from larger bed/higher acuity facilities Attracting patients who are established at larger facilities Attracting and retaining providers Limited resources Constant battle against thin financial margins
3© 2013 MCG. All Rights Reserved. The Big Picture: Rural Health (continued) The Advantages Personalized care: We know our patients Smoother transitions for change –Ideas easily escalated to senior leadership –Can make changes quickly
4© 2013 MCG. All Rights Reserved. Memorial Health Center Level III trauma care and Critical Access Hospital in northern Wisconsin Celebrated 50 years of service in 2012 Partnered with Aspirus, Inc in 2001 Embarked on Journey of Excellence in 2008
5© 2013 MCG. All Rights Reserved. Memorial Health Center (continued) Not-for-profit, Primary Care Hospital 5 Primary Clinics Specialty Clinics Pharmacy Therapy Centers Public Fitness Center Skilled Nursing Facility Swing Bed Program Assisted Living Facility Senior Income Eligible Apartments
6© 2013 MCG. All Rights Reserved. Memorial Health Center: Challenges Effects and causes Inaccurate status determinations Patient dissatisfaction: Delays, financial impact of inaccurate status determinations Staff stressed: Monday & early morning UR backlog, struggling with medical necessity and required documentation Providers frustrated: Poor coordination, lack of structured process 30-day readmissions at 9.1% Financial challenges: Reimbursement rates
7© 2013 MCG. All Rights Reserved. Criteria for a Potential Solution Needed a program that would impact: Patient care and safety Patient, provider, and staff satisfaction Financial standing Chose Web-based acute care guidelines from MCG: Inpatient & Surgical Care General Recovery Care
8© 2013 MCG. All Rights Reserved. Pre-Development Steps Early buy-in from senior leadership Began trial process in May 2011: UR RN notified of all admissions during office hours Began to manually track inappropriate admissions, inappropriate status, and changed status Trialed a binder with common care guidelines for ED physicians
9© 2013 MCG. All Rights Reserved. Planning Stage Needed an improved process to cover 24/7 utilization review Developed a policy and procedure defining process Utilization Review Committee approval Education provided to ED committee and medical staff and subsequent approval of new process Education provided to departments and staff
10© 2013 MCG. All Rights Reserved. Potential Obstacles: Budget & Staffing Smart phones with 24/7 access to the care guidelines On call compensation Physician advisor role Lesson Early buy-in from senior leadership pays off
11© 2013 MCG. All Rights Reserved. Implementation 24/7 utilization review program initiated (September 19, 2011) 1.UR nurse contacted (all admissions) 2.UR nurse determines appropriate admission status using care guidelines that can be accessed on the smart phone
12© 2013 MCG. All Rights Reserved. Implementation (continued) 3.Admitting provider and UR/charge nurse sign MHC Utilization Review Admission Determination with appropriate status checked 4.Relevant care guideline printed and placed – with criteria highlighted – in medical chart under Physician Orders 5.Daily review documentation and notes written directly on printed guideline
13© 2013 MCG. All Rights Reserved. Outcomes: Before and After Remember those challenges? Inaccurate status determinations –More accurate admissions –30-day readmission rate reduced from 9.1% to 5.6% –Quality Measure benchmarking Patient dissatisfaction –Patient satisfaction scores rose sharply
14© 2013 MCG. All Rights Reserved. Outcomes: Before and After Remember those challenges? Inaccurate status determinations –More accurate admissions –30-day readmission rate reduced from 9.1% to 5.6% –Quality Measure benchmarking Patient dissatisfaction –Patient satisfaction scores rose sharply
15© 2013 MCG. All Rights Reserved. Outcomes: Before and After (continued) Remember those challenges? Staff stressed –Smart phones support flexible hours, happier UR nurses –Increased sense of teamwork –Time savings across departments (medical records, registration, coding, billing) Providers frustrated –Greater sense of trust among providers –Proactive referrals for therapies, skilled nursing facility placements or home health during the admission process Financial challenges –Billable observation hour reimbursement increased $226,666 or 64%
16© 2013 MCG. All Rights Reserved. Outcomes: Before and After (continued) Remember those challenges? Staff stressed –Smart phones support flexible hours, satisfied UR nurses –Increased sense of teamwork –Time savings across departments (medical records, registration, coding, billing) Providers frustrated –Greater sense of trust among providers –Proactive referrals for therapies, skilled nursing facility placements or home health during the admission process Financial challenges –Billable observation hour reimbursement increased $226,666 or 64%
17© 2013 MCG. All Rights Reserved. Driving Effective Care Evidence-based guideline at providers fingertips for all admissions Documentation winsCare plan preparation Faster insurance and clinical reviews Overall, streamlined process from admission to discharge
18© 2013 MCG. All Rights Reserved. Questions? Please contact us. Jessica Faude, RN-BC Sandra Clarke, RN, BSN Jeremy Rittierodt, MSN, RN, CCM, CTT+ Memorial Health Center MCG Doyle Award careguidelines.com/content/doyle-awardcareguidelines.com/content/doyle-award
The Bed Management Center BMC. BED MANAGEMENT CENTER STAFFING Manager Assistant Manager Care Coordinators(RNs) 3 Admission Coordinators.
MiPCT Embedded Case management Barriers to developing an embedded Case Management program.
COST CONTAINMENT. Outcome Management Karen Niner RN BSN Manager Outcome Management department.
Community Care of North Carolina The Honorable Verla Insko N.C. House of Representatives.
Health Care Home and Care Transitions March 15, 2013 Hosted by RARE Operations Partners: Institute for Clinical Systems Improvement, Minnesota Hospital.
Introduction to Standard 5: Patient Identification and Procedure Matching Advice Centre Network Meeting Nicola Dunbar March 2013.
Care Coordination What is it? How Do We Get Started?
Confidential: Quality Improvement Material Case Management In a Primary Care Setting.
© 2013 MCG. All Rights Reserved. BEST PRACTICE RAC PREPARATION Jeremy Rittierodt, MSN, RN, CCM, CTT+ Account Executive, MCG May 15, 2013 Greg Borden, RN.
INDICIA TM FOR UTILIZATION REVIEW Build your business case Created by Milliman Care Guidelines For hospital decision-making teams.
Bundled Pricing Medicare’s New Payment Model Bundled Payments What Is It? How to Manage Bundling Models Marty Brutscher, McBee Associates.
SC Acute Inpatient Glycemic Management’s (IGMP) Needs Assessment Sponsors: Diabetes Initiative of South Carolina (DSC) South Carolina Organization.
Texas Health Care Network – Agency Presentation. 2 What’s New Texas House Bill 7 (HB-7) Health Care Networks Coventry Workers’ Comp Network Out of Network.
Bridging Medication Across Settings of Care Richard Ricker, RPH, MBA Sparrow Hospital Barbara J. Smith, LBSW, MS, CHC, NHA Burcham Hills DATE: May 29,
Eligibility, Benefits, and Pre-certifications Availity Customer Connection 2011 ©2011 Availity, LLC | All Rights Reserved 1 Rev
ICD -10 STAFF AWARENESS WHAT IS THIS COURSE? This course is designed to provide a basic awareness and understanding of ICD-10 and why it is so critical.
How the MEDISCRIBE © System Works © clark 2010 ASSISTED LIVING ASSISTED LIVING MEDISCRIBEMEDISCRIBE© Copyright © Clark 2010 – Patent Pending ALL RIGHTS.
The Big Puzzle Evolving the Continuum of Care. Agenda Goal Pre Acute Care Intra Hospital Care Post Hospital Care Grading the Value of Post Acute Providers.
Because your patients come first. Coding Jeopardy OutpatientObservationInpatientER / CC 200 Final Jeopardy.
A New Way to Look at the Business of Healthcare Nancy Nahlik Missouri Baptist Medical Center BJC HealthCare March, 2014.
PwC and Medical Necessity Issues and Concerns Emerging OIG scrutiny on medical necessity; nearly 500 hospitals on national target list for Medicare compliance.
Health Plans and Hospitals: Working Together to Prevent Readmissions - A Collaborative Approach to Transition Management July 30, 2013 Hosted by the RARE.
Hospital Patient Safety Initiatives: Discharge Planning Michele Kala, RN.
Billing & Documentation for Professional Charges for Clinical Trials.
Improving Patient Transitions: Building Social Networks across the Care Continuum Suneela Nayak, MS RN Nan Solomons MS Shelly Shibles, BSN RN.
The National Medicare RAC Summit “The Basics of Preparing for and Responding to RAC Demands” March 5, 2009 Presenter: Kathy Skrzypczak Assistant Vice President,
WRHA Palliative Care Program February 2013 Lori Embleton, Program Director Mike Harlos, Medical Director.
Introduction In 2005, comparisons were made internally by word of mouth and externally with other Tenet Healthcare Corporation hospitals, Georgia Hospitals.
1 Long-term Care Vermont’s Approach Individual Supports Unit Division of Disability and Aging Services Department of Disabilities, Aging & Independent.
Exhibit 1 NOTES: Other setting of usual care includes: neighborhood or family health center, free standing surgery center, rural health clinic, company.
Care Coordination Program for Heart Failure Susan Levine RN Director Clinical Resource Management Carolyn Timmons BSN,RN Lead Clinical Care Coordinator.
LeadingAge PA Grounds for EHR adoption in LTC 06/19/2015.
Copyright © 2006 Elsevier, Inc. All rights reserved Chapter 15 The Health Care Organization and Patterns of Nursing Care Delivery.
UNDERSTANDING HEALTH INSURANCE AND YOUR OPTIONS. HEALTH INSURANCE BASICS Presented by [insert organizations name]
DMAS Office of Behavioral Health 1 Department of Medical Assistance Services Substance Abuse Case Management (H0006) 2013.
Real Time Abstraction A Multidisciplinary Approach.
Community Care Coordination and Case Management Kansas Public Health Association, Inc Fall Conference.
Collaboration for Referral to Mayo Clinic Health System COMPASS Medical Home Inpatient/ ED Transitions RN January 2014.
Indiana Community Health Centers from the State Perspective A Presentation to Indiana Council of Community Mental Health Centers.
JOINT COMMUNITY VENTURE SAVANNAH, GEORGIA CHATHAM COUNTY SHONDRA DAVIS RN AMEDISYS HOME HEALTH DEE DEE SEAGRAVES RN ST. JOSEPH’S/CANDLER HEALTH SYSTEM.
Medical Home Port EMDEC BRIEF HMCM BLAKE WEST/HMCM KEITH STAPLES INDEPENDENT DUTY PROGRAM MANAGERS ENLISTED MEDICAL HOMEPORT CHAMPIONS.
Essentia Health Ely Clinic Age and Disabilities Odyssey Health Care Homes – Minnesota Style June 17, 2013 Essentia Health - Ely Clinic Health Care Home.
Magnet Status Looking for Quality Patient Outcomes: The American Nurses Credentialing Center's Magnet Program Recognizes Excellence in Patient Care.
Tad P. Fisher Executive Vice President Florida Academy of Family Physicians Patient Centered Medical Home A Medicaid Managed Care Alternative.
1 SOUTHCOAST HOSPITALS GROUP | Charlton Memorial Hospital | St. Luke’s Hospital | Tobey Hospital Patient Access Intake Center Transitioning Revenue Cycle.
Beyond Change: Transforming Culture, Care and Communities APHCAs 28 th Annual Conference and Trade Show Alabama Primary Health Care Association 2013 Annual.
Ronald H Kilmer, RN, Ret.. "Medicare won't pay if we charge them for observing you, because it's not a medical necessity.."
Electronic Triage comes to the North Bay Regional Health Centre Emergency Department Cathy Park RN,Manager Clinical Informatics Donna Labreche, RN, Co-ordinator,
Advanced Illness Management Sutter Health Lois Cross RN BSN ACM Sutter Health
1 Implementing Internet Web Sites in Counseling and Career Development James P. Sampson, Jr. Florida State University Copyright 2003 by James P. Sampson,
© 2017 SlidePlayer.com Inc. All rights reserved.