© 2013 MCG. All Rights Reserved. CREATING A 24/7 UTILIZATION REVIEW PROGRAM IN A CRITICAL ACCESS HOSPITAL Sandra Clarke, RN, BSN (Medical/Surgical Director)

© 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


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


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


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


Memorial Health Center: ChallengesEffects 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


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


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


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


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


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


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


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


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


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%


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%


Driving Effective Care

Evidence-based guideline at provider’s

fingertips for all admissions

Documentation wins

Care plan preparation

Faster insurance and clinical

reviews

Overall, streamlined process from admission to

discharge


Questions? Please contact us.

• Jessica Faude, RN-BC [email protected]

• Sandra Clarke, RN, BSN [email protected]

• Jeremy Rittierodt, MSN, RN, CCM, [email protected]

Memorial Health Center www.memhc.org

MCG www.careguidelines.com

Doyle Award careguidelines.com/content/doyle-award

mailto:[email protected]



http://www.memhc.org/

http://www.careguidelines.com/

http://www.careguidelines.com/content/doyle-award



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© 2013 MCG. All Rights Reserved. CREATING A 24/7 UTILIZATION REVIEW PROGRAM IN A CRITICAL ACCESS HOSPITAL Sandra Clarke, RN, BSN (Medical/Surgical Director)