Automating referrals aids discharge processes

Feb. 26, 2010

Software-as-a-service model sends data electronically to multiple facilities, easing case-management staff workload.

A case manager enters data into the Inova Health System SaaS portal. The system previously had no standardization among its five hospitals to ensure staff was following proper procedures.

At Falls Church, Va.-based Inova Health System, up to two full days were needed to process and receive a reply on a simple nursing home referral: gathering, copying and collating paper records, faxing them to the facility, playing phone tag with facility staff, talking with staff, relaying information to patient and family, responding to requests for more information from the facility— and doing it all again for the next facility.

Worse yet, says Linda Sallee, RN, vice president, case management, “There was no standardization among the system's five hospitals to ensure that all case managers were following the same protocol, no way to readily identify and correct patterns of problems with individual facilities, no way to track and improve Inova's record in successfully placing its patients.”

When Sallee arrived at Inova five years ago, the system was already assessing its discharge planning process with an eye to automating and interfacing it with its chart-tracking and case-management module. At the time, only two companies were capable of doing that, and Sallee arranged for both of them to present their products to Inova's five case-management directors and selected case-management and IT staff.

Only one, Allscripts Care Management (ACM), could provide what Inova was looking for: a national database with not just nursing homes and other hospitals but providers of acute rehabilitation, durable medical equipment, IV infusion and outpatient physical therapy.

ACM is a software-as-a-service (SaaS) application. Rather than having to install, manage, maintain and update its own software, Inova uses a Web browser to access ACM's secured site, where the data is stored. The company takes care of security, backups and disaster recovery.

“We built in interfaces with everything at Inova we could,” says Sallee. “All of our medication records, lab results, and radiology records are in ACM, along with patient demographic information and any reports that have been transcribed.

“We're able to electronically select multiple facilities and send all that data to them instantly and simultaneously,” she adds. “Those who are subscribers are able to send their answer electronically; nonsubscribers get a fax from us with instructions to reply to the ACM call center. ACM also provides a packet of information for every facility, including directions for getting there, that we can print and provide to the patient.”

Easy distribution system

In addition, Sallee points out, the health system now has documentation of everything it does. “If there are things I need to send to a nursing home that aren't in the system, I can fax those pages to ACM and they scan and attach them to the electronic referral,” she says. “If I later want to send the information to somebody else, all I have to do is push a button as opposed to reassembling everything and faxing it again.”

Because Inova is in the Washington, D.C., area, Sallee explains, a percentage of its patient population is people on vacation, who naturally want to go back home after discharge. “Before, I would go on the Internet and their home town, see what hospital was there, call and talk with their social worker to get a list of nearby after-care providers, then call and/or fax those facilities. With ACM, I just enter the ZIP code and can access the providers directly, just as I do locally.”

Making the process simple, quick and efficient is one benefit of automation. Another is the amount of valuable information it delivers. Sallee can run reports, by individual or by hospital, and see exactly what case-management staff is doing, such as how many referrals they are making to which facilities and in what categories of patient disposition, and whether or not they are following the established protocols.

ACM provides 85-95 percent of the information Sallee uses to create a monthly case-management scorecard that allows senior leadership at both the system and hospital levels to stay on top of the discharge planning function. For example, Inova owns three nursing homes and an acute-rehabilitation facility. In tracking what percentage of system referrals and actual patients were going to those facilities and how they performed, “We found that they were taking longer than others to respond to us, so we were able to address and fix that,” she says.

“At one of our hospitals, a lot of the home-health referrals were going to a particular agency,” she adds. “The director was able to identify which case manager was involved and sit down with her to review the process she needed to follow.”

Committee drives implementation

Sallee describes ACM as an intuitive system that was not hard for staff to learn and is not IT intensive. Allscripts assigned a project manager and a clinical expert to work with Inova and head up their project steering committee, which included Sallee, her directors and someone from IT. Also represented on the committee was the system's group of “super users,” individuals selected from each of the five hospitals to serve as trainers in a train-the-trainer process.

The system was rolled out one hospital at a time, starting with the smallest and ending, about 10 weeks later, with the biggest. A year later, when Allscripts developed an ACM utilization-management (UM) module that offered to track and boost compliance with contracting and government regulations, Inova added it. Communicating with managed-care payers, like communicating with nursing homes, was always a trial, with case managers spending hours on the phone to get authorization for care and hours more preparing copies of required clinical data to fax.

Today, staff can autofax to payers, create and automatically populate often-used forms, and build customized, interactive work lists for different staff to use. “If I'm a case manager working rooms 4 to 20 on the 4th floor, I can set up my profile so that any patient admitted to those rooms goes on my work list,” Sallee explains. “I can see how many days each patient has been in the hospital, who their payer is and when I'm supposed to call them, when I did my last medical-necessity review and when my next one is due.”

Making the process simple, quick and efficient is one benefit of automation. Another is the amount of valuable information it delivers.

With the SaaS solution, time to admission (to nursing homes) from first referral and time from admission (to the hospital) to discharge have dropped at least three days at all five hospitals, she says, and length of stay is down about 12 percent.

Also, says Sallee, “It's much easier to place patients out of state, with fewer delays; we've even placed patients internationally with ACM.

“We're now also able to track avoidable days, delays and denials in real time. For example, we used to document denials only at the end of the denial process rather than at the beginning, but now we can work on denial prevention instead of denial management. I can run a report of case managers whose cases are being denied, find out why, and either do remedial training or develop an action plan to address the issue. If we see a pattern with a particular payer, we'll be able to document it and take it up with them.”

Pressed to identify problems implementing and using ACM, Sallee offers, “Some of our more complicated interfaces — with medication administration and labs — took a bit longer to go live. And, as with any Internet-based program, it usually slows down a bit in the afternoon, when the West Coast comes online. But Allscripts has really worked on that, buying more servers and making sure their connector lines are fast.

“I'm pretty ambitious,” Sallee says. “So, I've always got something else I want to do. Right now, we're working on allowing selected payers to get into the system to access clinical information on their patients and document authorizations — without seeing other things, like our avoidable days and delays.”

Lauren Phillips is president of Phillips Medical Writers, based in Bellingham, Wash.

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