1. GETTING IT RIGHT FROM THE START: Emergency Department Admission Classification for Medicare Patients Building the Bridge: Excellence through Innovation, Education and Financial Stewardship Grand Hyatt Hotel October 27, 2011
Sandy

2. Team Members Sponsor: Ad Hoc Team Members: Dr. Sandra Murdock
MD Champs:
Dr. William Mileski
Dr. Parham Parto
Team Members:
Kathy Nash, NP
Andrea Sunday, RN
Laurie Popovits, RN
Samantha McBroom, RN
Jamie West , CM
Team Leader:
Annette Macias-Hoag, RN
Ad Hoc Team Members:
Virginia Morales- Care Management
Melinda Tillman- ED Nursing Informatics
Jennifer Zirkle- Care Management
Facilitators:
Gina Butler, RN
Angel Male, RN
Sandy

3. Aim Statement
To decrease the percentage of Medicare patients admitted from the Emergency Department classified as full admission status, with a length of stay <24 hours, from 7.5% to 2% by June 30th, 2011.
Sandy

4. Why did we focus on Medicare patient admissions?
Background
Why did we focus on Medicare patient admissions?
In August 1, 2008 a Zone Program Integrity Contractors (ZPIC) revealed an overpayment claim of approximately 1 million dollars from our institution
Annette
Zone Program Integrity Contractors are organizations hired indirectly (or in connection with other CMS affiliated contractors) by CMS to perform a wide range of medical review, data analysis and Medicare audits. In a number of instances, the ZPICs have been noted to be suspending providers from the Medicare program based on variety of alleged statutory and / regulatory violations.
In August 2008 a ZPIC audit of UTMB post payment claims identified approximately 1 million dollars in overpayments of inpatient admissions, therefore here we are today. Hospitals are sometime able to recover overpayments.

5. Background Data
Admission vs. Observation classification status was recognized by hospital leadership as an opportunity for improvement.
Scope was narrowed to Internal Medicine Admissions (Medicare) that had a length of stay (LOS) less than 24 hours.
About 31% of patients at UTMB are admitted through the Emergency Department.
Currently, 7.5% of Internal Medicine Admissions (Medicare) had a length of stay (LOS) less than 24 hours.
Annette
From September through December 2010—about 7.5% of internal medicine admissions through the ED had a length of stay of less than 24 hours. 5

6. Performance Measures Full Admits with LOS < 24 hrs
Intervention 1 (Care Management)
Intervention 2 (Hospitalist Consult)
Intervention 3 (Education) Implemented Post Graduation
Data Source: EPIC EMR / Invision
Annette
Performance measures were based on 3 possible interventions.
2 of the 3 interventions were already planned before the CS & E project developed.
Thankfully we were able to use an electronic data collection source to monitor our progress

7. Baseline Data: 09/10 to 01/11 Pre-Intervention Annette
The above slide is a control chart of our pre-intervention data by week for fiscal year This chart shows us that the average of Internal Medicine patients with Medicare who were fully admitted through the Emergency Department and had a length of stay less than 24 hours was 7.5%.

8. Process Analysis Brainstorming Process Flow Mapping
Cause and Effect Diagram (Ishikawa)
Pareto Chart
Kathy
Our project unfortunately was not a LEAN project, so we were unable to incorporate those tools. However, we were able to use and learn the tools mentioned here to help us look at the implemented changes.

9. Process Flow of Admissions from the ED
Kathy
Although you may not be able to see this from where you are sitting, this is our pre-intervention flowchart for patients admitted through our Emergency Department.
We decided to use swim lanes to look at each entity within the process to help us visually identify the areas.
The process flow supported the importance of Internal Medicine and Case Management presence in the Emergency Department.

10. Cause and Effect Diagram
Kathy
When our team met to brainstorm for our project, we chose to use a cause and effect diagram to identify the main issues contributing to the Problem Statement.
We discovered many issues were outside the scope of the Emergency Department, which prompted the addition of our Ad hoc team members.
After completing the diagram, it demonstrated the need for continuous support for Emergency Department providers with education to guide them in determining the appropriate admission classification of patients.

11. Pre Intervention Data – Pareto Chart
Kathy
This pareto chart was created using our pre-intervention data. It visually demonstrates the days of the week in which we have the highest number of admitted patients with a length of stay less than 24 hours to reinforce that appropriate resources were present on the days needed.
In summary, 75% of Medicare patients were admitted during the weekdays.

12. Working Towards Improvement
Care Manager stationed in the Emergency Department for 4 hours a day, Monday through Friday
Hospitalist Consultation for Emergency Department patients requiring possible admission Monday through Friday from 8am to 9pm
Education to Emergency Department Providers provided during staff meetings
Education to residents at noon conference
Kathy
To start off, a care manager was placed in the Emergency Department for 4 hours a day to assist with proper classification at the point of entry to the hospital.
Dr. Sandra Murdock (VP of Health System Operation) and Dr. William Mileski (Interim Medical Director of the Emergency Department) collaborated with Dr. Randy Urban, (Chairman of the Department of Internal Medicine) and his team to implement their hospitalist model within the ED.
Our next step was education of the Internal Medicine Residents concerning regulatory and documentation requirements by CMS.

13. Results: Overall Interventions
Mileski
Here you can see our mean percentage score decreased with each intervention. Unfortunately, (at this point) we were not able to reach our projected goal of 2%. However, we were able to reduce our mean by 4%.

14. Intervention #3: Reference Card
Mileski
Referenced from New Mexico Medical Review Association

15. Results: Post CS&E Graduation
Mileski
Since our CS&E presentation, we implemented another intervention which was to provided reference cards, or cheat sheets to the residents in the ED. As you can see from here, with the combination of all three interventions, we were able to exceed our goal.

16. Return on Investment Full Admission Error 7.5% 4.1% Projected Cases 6234
Reduction in cases/yr 28
Overbilling/case
$ ,800.00
Overbilling/yr
$ ,400.00
ZPIC Audit Avoidance/yr
$ ,240.00
Samantha
We did not use the ROI tool provided in CS &E. We attempted to use it but it was difficult to understand and manipulate.
In this calculated ROI, the full admissions reduced from 7.5% pre-intervention to 4.1% post intervention; which resulted in a projected reduction in cases by 50%.
The estimated overbilling/per case is about $10,800 ($12,000 for Full Admission vs. $1200 for 23 hr obs).
The estimated overbilling/per yr is calculated by multiplying the reduction in cases/yr (28) by the amount overbilled/case (10,800); which results in $302,400. The ZPIC audit avoidance/yr was estimated by multiplying the overbilling/yr by the inability to recover payments of 10%. This percentage could be higher.

17. Return on Investment Year 0 Year 1 Year 2 Year 3 Costs $ (28,283)
Year 0
Year 1
Year 2
Year 3
Costs
$ (28,283)
Benefits
$ 30,240
Cost of Capital 9%
ROI
220.76%
NPV
$48,263
Samantha
The costs for the project were the number of hours the team worked on the project multiplied by their hourly salary. The benefits are the ZPIC audit and charges related to the recovery process. The ROI is calculated by (Net benefits- costs)/costs

18. Next Steps Monitor for improvement Full Time Care Managers
24/7 Hospitalist coverage
Education
Focus efforts on observation cases
Mileski
Continue to Monitor for improvement
Pursue the possibility of having Full Time Care Managers in the ED
Consider around the clock hospitalist coverage
Implement education to residents on routine bases
Focus efforts on observation cases incorrectly classified at admission

19. Lessons Learned Leadership involvement and support Staff ownership
Understanding of time commitment
Mileski

20. Questions???