8/14/13 2013 Morrisey Technology & Educational Conference 1 Best Practices: Case Management and Keys to a Successful Implementation Teresa Gonzalvo, RN, BSN, MPA, CPHQ, ACM Vice President, Care Coordination Sentara Healthcare Sherry Norquist, RN, BSN, ACM Manager, Care Coordination Sentara Leigh Hospital August 14, 2013 1 Sentara Healthcare • 125-years of service, not-for-profit organization • 11 hospitals; 2,572 beds; 3,825 physicians on staff • 13 long term care/assisted living centers • LTACH • 4 Medical Groups (650+ Providers) • Optima-453,118 member health plan • Sentara College of Health Sciences • $4.9B total operating revenues • $5.4B total assets • 25,000+ members of the team Virginia North Carolina 2 Integrated Health System Primary/ Specialty Care Hospital Emergency Care Ambulatory Care Long Term Care Home Health Care Rehab Care Health Plan 3
1) Samplestaff included in rounds are physicians, nurses, physical therapists, nutritionists, etc.
1Inpatient Redesign First Step in Improving Ability to Support Broader Efforts
Multifaceted Case Management Approach at Sentara Healthcare
Phase II
Revitalized Multidisciplinary Rounds: Representatives across different clinical disciplines collaborate to conduct joint rounds and create a patient-centeredcare plan1
Care Coordination Dyad Model: Social worker and care coordinator paired to improve coordination of care; staffing ratios re-evaluated to ensure adequate supportAccess Coordination:
Case managers embedded at all points of patient access (e.g., ED, OB, etc.) to ensure appropriate level of care provided
Medical Necessity Reviews: VPMA advisors, with support from external agency, reviews cases, interfaces with medical staff
Phase I Phase III
Post Acute Partnerships: Case management leaders will collaborate with post-acute care providers to improve transitions, information exchange, unnecessary transfers
Enhanced Technology: Case management system evaluation underway
Care Coordination Practice Council: New cross-continuum committee will integrate inpatient, ambulatory-based, and health plan case managers to improve communication and best practice sharing
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Care Coordination journey – consistent and standardization of our support services
• The Morrisey Concurrent Care Manager application is part of our solutions package
• Successful implementation is contingent upon detailed project planning, ongoing communication, staff education and practice
• Staff engagement with the design phase is necessary
• At the access points of the hospitals, RNs assess patients to determine medical necessity and provide transition planning
• The use of MCCM enables the RMC staff to seamlessly provide additional clinical information as needed or determine if a physician review is required
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Case Summary
• Topics currently is use– Comments – all notes on case– Concerns – key internal communications– Delays – avoidable delay capture– Saved Days – shortened LOS – Images – stores a picture of faxes sent– Payor Contacts – documentation of
communications with payors– Encounter sections – easy access to any Sentara
encounter since go-live (2/13/13)– Medical Nec. Reviews – all UM reviews
completed, including InterQual data – Denial Reviews – if denial received, can begin the
appeal process documentation– Physician Advisor – to send cases to PA’s for
review– User Defined for special things not covered
Discharge Facilitation ProcessQ. How do we know when we have a DCF Concern?
A. You will monitor the Discharge Facilitators work list all day
• You will click on the patient name to open the concern
• Patient data for locating patient in Epic will be in the header
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Resource Management Center• With the use of technology, and the right skill mix, this one-of-a-
kind Care Coordination hub manages hundreds of accounts daily, for 7 out of 11 hospitals
• This high-tech communication promotes timely and effective notification to our patients. Increased compliance with CMS and other regulatory guidelines due to standardization of workflows and reports
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The hospitals and the RMC are all on the same page
• Having the tools to help us
communicate enables us to
increase our efficiency
• The team is able to see notes
from their teammates, and the
VPMA or Physician
Advisors, in real time
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VPMA Dr. Scott Miller’s gift of THANKS!
Sentara Leigh’s Nurse Executive Genemarie, Care Coordinators and
• The MCCM application allows the RMC and hospital based staff to refer cases easily to contracted physician advisors or internally to a VPMA
• All of the many complex functions that happen within the hospitalized patient’s case are easily viewed by all members of the Care Coordination team
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Physician Advisor Work list• Resource Coordinator creates PA
referral
• Auto-populates to work list for PA
• Used for VPMA, PA, and E.H.R.
• PA responds
• Stethoscope alert appears for resource coordinator once PA responds
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Unit Based Care Coordination Team
• Unit Based Care Coordinators, Social Workers and Associate Care Coordinators spend their time with patients and their families
• These staff members use their clinical expertise to provide transitional planning and patient support, plan for the day, plan for the stay, as well as guiding the multidisciplinary team to remain on target for Length of Stay goals
Increased Staff Satisfaction • Having the admit/discharge date and time, I can
easily identify triage patients who are only in L&D a few hours and mass delete them or know that a status change will need to be sent if they are inpatient.
• I complete preliminary reviews on obstetric patients and set the NRD for when the patient should go home. This way I can easily see if a baby stays longer than the Mom and needs an auth or if a Mom takes more than 2 days to deliver and may need an auth.
-Patsy Duguay, RN
Resource Care Coordinator, RMC
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Lessons Learned
• Allow more time for staff to practice in the Test Environment
• Frequent and multimedia communication to key stakeholders and end users
• Define and run reports sooner than later
• Clarify expectations and timelines from both Morrisey and Sentara teams
• Ongoing assessment and evaluation via leadership, staff surveys (i.e. Zoomerang)
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What the Future Holds• Managing Transitions
Across the Continuum of Care
• As we strive to bridge the gap and ensure seamless transitions, we are seeking to engage our home care and skilled nursing facility providers in this endeavor
• Ongoing close collaboration with our community partners through the Long Term Care Council
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Dr. Gene Burke, VP of Clinical Effectiveness, discussing the Readmission initiatives with the
Long Term Care Council
Care Coordination Long Term Council Launched with the Hampton Roads
