The Mentor[R] Model: care management in the 21st century.Quality of care has become increasingly important over the last three decades, driven by the growth of managed care, increased customer expectations, changing demographics The attributes of people in a particular geographic area. Used for marketing purposes, population, ethnic origins, religion, spoken language, income and age range are examples of demographic data. , intensified governmental regulation, the Balanced Budget Balanced budget A budget in which the income equals expenditure. See: budget. balanced budget A budget in which the expenditures incurred during a given period are matched by revenues. Act and the Leapfrog Initiative. (1) New technologies and pharmaceuticals, coupled with the aging population, exert further pressure on providers to utilize costly resources in the most efficacious ef·fi·ca·cious adj. Producing or capable of producing a desired effect. See Synonyms at effective. [From Latin effic manner. With respect to inpatient care inpatient care Managed care Services delivered to a Pt who needs physician care for > 24 hrs in a hospital adjusted length of stay (ALOS), denials management and utilization management Utilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. (UM) have grown to bellwether Bellwether A leading indicator of trends. Notes: A bellwether stock is a stock that is used to gauge the performance of the market in general. General Motors was an example of a bellwether stock, hence the saying "What's good for GM is good for America. status for health care organizations tracking performance. (2) Case management, whether hospital-based, community-based or hospital-to-community, quickly became the panacea Some antidote or remedy that completely solves a problem. Most so-called panaceas in this industry, if they survive at all, wind up sitting alongside and working with the products they were supposed to replace. addressing many of these issues and met with some success. However, many of its deliverables (streamlining discharges, controlling costs and reducing denied days) distanced the physician from involvement and best practices. (3,4) Traditional case management evolved to meet these changing standards and challenges. (5) Criteria were adopted, policies and procedures Policies and Procedures are a set of documents that describe an organization's policies for operation and the procedures necessary to fulfill the policies. They are often initiated because of some external requirement, such as environmental compliance or other governmental developed and physician behavior targeted. The number of clinical guidelines guidelines, n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. and protocols increased exponentially ex·po·nen·tial adj. 1. Of or relating to an exponent. 2. Mathematics a. Containing, involving, or expressed as an exponent. b. . There was a shift from a financially driven model to a clinically aligned one. Demand and disease management programs were developed, and case management was transformed into care management under a continuous quality improvement umbrella. (6-10) The pivotal role of the physician in the process, however, is under-appreciated and under-leveraged. (11-13) To address this problem, a new program known as the Mentor[R] Model (Multidisciplinary Excellence, Nurturing Teamwork, for Optimal Resources) was developed by hospital leaders and the clinical staff at St. Joseph's Regional Medical Center in Paterson, N.J. Nurses, administrators and physicians retooled a traditional case management program that was led by nurses, based on financial deliverables and linked case managers to individual physicians. FIRMing up the process The new model of care management involves a system called FIRM (Floor Initiated Resource Management) that was put into place on each patient care floor. FIRM teams are led by physicians (employed or community-based) and also include a care manager, clinical social worker, nursing unit manager, resident physicians and miscellaneous personnel (students, pharmacists This is a list of notable pharmacists.
Another key element to the mentoring model is PURR (Physician Utilization Resource Recovery). Through PURR, the number and type of laboratory, radiologic radiologic Radiological adjective Referring to radiology , imaging studies and pharmacotherapeutics are tracked for each physician and compared to an institutional peer group by specialty. Monthly meetings are held for the FIRM and PURR teams during which performance data are reviewed, challenges identified and problems addressed. On a daily basis, another team called WARR WARR World Airline Road Race WARR Workload and Resource Report WARR Worldwide All-Request Radio (AT&T) WARR Wide Angle Reflection and Reflection (GPR) (Winning Admissions and Recovering Rejections) meets to review concurrent denials. The group also looks at admissions, guidelines, practice patterns of attending physicians and residents, operational efficiency, bed management and managed care. Physician practice issues are handled on a one-to-one basis. If a patient's care plan is problematic (fails to meet diagnostic criteria or involves inappropriate tests, delays in results or consults) the FIRM attending calls and speaks directly to the private medical attending (PMA PMA (papillary-marginal-attached), n a system of epidemiologic scoring of periodontal disease devised by Schour and Massler in which the symbols denote the areas involved in gingival inflammation. PMA Progressive muscular atrophy ). The discussion is one of mentorship based on best practices and is never punitive. Guidelines or clinical practice protocols are used in a coaching framework. This is done because studies suggest that physicians respond more favorably fa·vor·a·ble adj. 1. Advantageous; helpful: favorable winds. 2. Encouraging; propitious: a favorable diagnosis. 3. to new information concerning quality of care or cost when another physician--particularly one in a clinical leadership position--communicates the message. If the FIRM leader is unable to modify bedside behavior, the chief/director of the service, the chairman of the department and chief medical officer are notified. Testing the model With the mentoring model in place, a study was conducted at St. Joseph's, a 780-bed inner city tertiary care tertiary care Managed care The most specialized health care, administered to Pts with complex diseases who may require high-risk pharmacologic regimens, surgical procedures, or high-cost high-tech resources; TC is provided in 'tertiary care centers', often hospital, from April 2001 to August 2002 to see how mentoring was affecting patient care. The study was based on data from ALOS, denials, guideline guideline Medtalk A series of recommendations by a body of experts in a particular discipline. See Cancer screening guidelines, Cardiac profile guidelines, Gatekeeper guidelines, Harvard guidelines, Transfusion guidelines. compliance, recovered days and physician utilization profiles. There were 27,025 patient stays measured in the 2001-2002 dataset, and 28,321 patient stays measured in the 2000 to 2001 dataset. Of these, the Medicare patient stays numbered 6,834 in 2001-2002, and 7,269 in 2000-2001. Guidelines, including standing orders for the top 25 drug related groups (DRGs), were developed through nurse-physician collaboration. The most dramatic changes occurred in length of stay. Prior to the initiation of the daily concurrent denials review process (in August, 2001) and the FIRM process (Nov, 2001) the overall length of stay averaged 5.8 days; some months saw spikes at 6.65 days, 6.14 days. [ILLUSTRATION OMITTED] Medicare lengths of stay prior to the initiation of the Mentor[R] Model included months with LOS as high as 9.0 days, the average Medicare LOS at 8.04 days. After implementing the Mentor[R] Model, length of stay dropped to an average of 5.44 days, with some months as low as 5.19 and 5.22 days. After the initiation of the strategy, Medicare LOS dropped to 6.7 days, 6.9 days for an average of 7.03 days(See graphs pg. 24). Using Carey and Lloyd's (14) rules for interpreting control charts, when seven or more data points fall above or below the midpoint mid·point n. 1. Mathematics The point of a line segment or curvilinear arc that divides it into two parts of the same length. 2. A position midway between two extremes. , a trend is established at a new level. In addition, when monthly LOS for the 10 months prior to the initiation of the Mentor[R] Model were compared to the 10 month period following the implementation of the strategy, a statistically significant difference in the average LOS for both overall (p<0.0001) and Medicare LOS (p<0.0001) was found. Managed care denial rates were measured as the number of denied days (complete denials or level of care changes) divided by the number of managed care days. Our area of interest was clinical denials. Clinical denied days were defined as those that a managed care plan deemed totally non-reimbursable due to one or more reasons (e.g., lack of medical necessity, delay in a procedure, service or discharge). [ILLUSTRATION OMITTED] [ILLUSTRATION OMITTED] Clinical denials were also defined as those denials reimbursed at a lower rate usually because, in the managed care plan's view, the services could have been provided in an alternative, less expensive setting. Other types of denials (administrative denials, or denials related to lack of pre-certification, or notice of admission, etc.) were not included in the analysis, as we were interested in those denials most affected by clinical practice and documentation. Although the differences were not as striking as the differences in length of stay, statistically significant lower denial rates were found in the period following the implementation of the project (p<0.003). Denied days "recovered" concurrently or retrospectively were tracked during the data collection period. Recovered days were defined as days that were initially denied or lowered by the managed care company, but with the submission of additional clinical information were then overturned or upgraded. Prior to implementation of the strategy, recovered days rates were as low as 3 percent; after the implementation of the program, monthly recovered day rates hovered around the 35 percent range, with an average of 27 percent (p<0.0001). This change in the percentage of recovered days is undoubtedly related to our success in denials in denial Psychiatry To be in a state of denying the existence or effects of an ego defense mechanism. See Denial. prevention. In addition, it should be noted that the most recent months' recovery rates may not reflect future success with the retrospective denials recovery process. Individual physician profiles were used to reinforce positive change, and to support the overall effectiveness of the Mentor[R] Model at the level of physician practice. These individual profiles included information about length of stay, denial rates, cost of care data, as well as mortality statistics. They were compiled at the DRG DRG, n the abbreviation for diagnosis-related group. DRG see dorsal respiratory group. DRG Diagnosis-related group Managed care A unit of classifying Pts by diagnosis, average length of hospital stay, and level, shared with chairmen and included as part of a more global discussion of an individual physician's performance. For physicians in group practice, data were compiled at the group, rather than the individual level of analysis. Factors for success It is essential to recognize that many factors contributed to the successes of the Mentor[R] program. Simply moving the denial process from a selective retrospective one to a comprehensive concurrent one allowed the intervention team to identify the appropriateness of clinical decision-making at the bedside in "real time." (15) The insurance status is transparent to the process and the focus of the reviews is on quality outcome parameters rather than cost reduction. (16) Our limited experience with occupational health services health services Managed care The benefits covered under a health contract delivery indicates that there are also substantial deliverables. (17) The regular consistent use of admission and discharge criteria reduced the number of low quality admissions (clinical problems for which an outpatient workup work·up n. Abbr. w/u A thorough medical examination for diagnostic purposes. is appropriate) and facilitated bed turnover. (18) The authors recognize the crude problematic nature of ALOS as a surrogate surrogate n. 1) a person acting on behalf of another or a substitute, including a woman who gives birth to a baby of a mother who is unable to carry the child. 2) a judge in some states (notably New York) responsible only for probates, estates, and adoptions. performance indicator. (19) However, when risk adjusted and combined with specific utilization data (imaging studies, laboratory tests and drugs) and compared to peer group data, trends become more useful and distinct. (20,21) Maintaining and utilizing physician performance profiles in the context of 1:1 proactive discussions also produced substantial persisting results that reduced ALOS, denial rates, and the utilization of drugs, imaging studies and laboratories. (22) Relational coordination, frequent, accurate, timely communication plus problem-solving, shared knowledge and goals, and mutual respect among health care professionals also is shown to improve quality of care and decreased ALOS. (23) [GRAPHIC OMITTED] The intensity and demands of the Mentor[R] program were reflected in significant turnover of the care management staff. Assignment changes, patient ratios and salary contributed to the dissatisfaction. (24) Staff vacancy rates ranged from 8 percent to 15.2 percent. However, stability was achieved through FIRM rounds, proactive physician involvement and leadership, and collaboration with nursing leadership. (25) Twice a week, the WARR effort was taken to a specific FIRM; other days, morning rounds were incorporated. A weekly teaching case was presented to residents and posted in the physician's lounge. The FIRM attending had the primary coaching function. (26) Each stage of the process was similar--performance data, peer comparison information, specific cases and opportunities for improvement. If the attending physician did not respond (25 percent), the service chief/chair provided proactive counsel. A smaller number of the clinical enterprise attending physicians were ultimately counseled by the chief medical officer/senior vice president for medical affairs. The integration and redefining of key processes (both traditional and non-traditional) associated with the management of inpatient inpatient /in·pa·tient/ (in´pa-shent) a patient who comes to a hospital or other health care facility for diagnosis or treatment that requires an overnight stay. in·pa·tient n. and outpatient care will not only result in measurable improvement of quality outcomes--such as LOS reduction and appropriateness of care--but also changes in physician behavior and denial reduction. The foundation of the Mentor[R] program is the collaboration on a daily basis among the key stakeholders Stakeholders All parties that have an interest, financial or otherwise, in a firm-stockholders, creditors, bondholders, employees, customers, management, the community, and the government. , coupled with support from hospital administration and physician leadership. If hospitals are focused solely on a reactive approach to quality and denial issues, their successes will be limited. Hospitals must engage in both retrospective approaches (PURR, physician profiles) and preventive and concurrent strategies (FIRM, WARR) in order to achieve optimal results. IN THIS ARTICLE ... A study shows how a new mentoring program helped lower length of stay and managed care denials at a New Jersey medical center. References 1. "Slow Pay and Claims Denials: Welcome to the world of managed care." Hosp.Case Manag. 6(6): 109-112, 1998. 2. Mullahy, CM. "The Effective Integration of Utilization and Case Management." Case Manager 11(2): 53-56, 2000. 3. Gotham, CF., Bayliss D., Luzinski, CH. and others. "A Cost-effective Model of Community Case Management." Case Manager. 11(3): 75-79, 2000. 4. Daniels, S. "Using Hospital-based Case Management to Reduce Payer Denials." Healthcare Financial Management. 53(5): 37-39, 1999. 5. "Case Managers must take a Proactive Role in Managing Denials." Am. Health Consultants. 10(4): 49-51, 2002. 6. Horn, SD. "Quality, Clinical Practice Improvement and the Episode of Care." Managed Care Quart quart: see English units of measurement. . 9(3): 10-24, 2001. 7. Ireson, CL., Grier, MR. "Evaluation of Variances in Patient Outcomes." Outcomes Management Nursing Pract. 2(4): 162-166, 1999. 8. Jaques, SE. "Using a Physician-aligned Case Management Model to Influence Hospital Length of Stay and Payer Denials." Lippincott's Case Management 7(3): 113-120, 2002. 9. Jarlier, A., Charvet-Protat, S. "Can Improving Quality Decrease Hospital Costs?" J. Quality Health Care. 12(2): 125-131, 2000. 10. Rieve, JA. "Best Practices and Outcomes." Case Manager. 11(1): 27-28, 2000. 11. Levinson, W., D'Aunno, T., Gorwara-Bhat R. and others. "Patient-physician Communication as Organizational Innovation in the Managed Care Setting." Am.J.Managed Care. 8: 622-630, 2002. 12. Millenson, ML., Demanding Medical Excellence. Doctors and Accountability in the Information Age. Chicago: The University of Chicago Press The University of Chicago Press is the largest university press in the United States. It is operated by the University of Chicago and publishes a wide variety of academic titles, including The Chicago Manual of Style, dozens of academic journals, including , 1997. p. 129. 13. Reed M., Devers, K., Kandon, B. "Physicians and Care Management: More acceptance than you think." Issue Brief. No. 60. Center for Studying Health System Change The Center for Studying Health System Change (HSC) is a nonprofit, nonpartisan policy research organization located in Washington, D.C. HSC designs and conducts studies focused on the U.S. . Wash. DC. 2003. 14. Carey, RG. & Lloyd, RC. Measuring Quality Improvement in Healthcare; A Guide to Statistical Process Control Applications. Quality Resources: New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of , 1995 p 69. 15. "Case Managers Reorganize re·or·gan·ize v. re·or·gan·ized, re·or·gan·iz·ing, re·or·gan·iz·es v.tr. To organize again or anew. v.intr. To undergo or effect changes in organization. to Challenge Claims Denials." Hosp.Case Manag. 7(8): 133-6, 1999. 16. Rieve, JA. "Databases, Program Outcomes, and Report Cards." Case Manager. 13(1): 26-7, 2002. 17. Salazar, MK. "Maximizing the Effectiveness of Case Management Service Delivery." Case Manager. 11(3): 58-63, 2000. 18. Felt-Lisk, S., Mays, GP. "Back to the Drawing Board: New directions in health plans' care management strategies." Health Tracking. 21(5): 210-217, 2002. 19. Clarke, A. "Length of In-hospital Stay and Its Relationship to Quality of Care." Qual.Saf.Health Care. 11(3): 209-210, 2002. 20. Thomas, JW., Guire, KE., Horvat, GG. "Is Patient Length of Stay Related to Quality of Care?" Hosp.Health Services Admin. 42(2) 489-506, 1997. 21. Murphy, ME., Noetscher, CM. "Reducing Hospital Inpatient Length of Stay." J.Nurs.Care Qual. 11(2): 40-54, 1999. 22. Ross, G., Johnson, Castronova, F. "Physician Profiling physician profiling Managed care A method of cost containment that focuses on the patterns of health care provided by a single physician or group, instead of on specific clinical decisions; the resulting profile is then compared to other norms based on Decreases Inpatient Length of Stay even with Aggressive Quality Management." Am.J.Med.Qual. 15(6): 233-237, 2000. 23. Gittell, JH., Fairfield, KM., Bierbaum, B. and others. "Impact of Relational Coordination on Quality of Care, Postoperative post·op·er·a·tive adj. Happening or done after a surgical operation. postoperative after a surgical operation. postoperative care Pain and Functioning and Length of Stay." Med. Care. 38(8): 807-819, 2000. 24. Rieve, JA. "Proving the Value of Case Management." Case Manager. 11(2): 42, 2000. 25. Adams-Best, L., "Strides in Care Management: The development of a framework to facilitate quality outcomes." Healthcare Management Forum. 14(2):44-50, 2001. 26. Waters, TM., Budetti, PP. Reynolds, KSE KSE Karachi Stock Exchange KSE Kuwait Stock Exchange KSE Korea Stock Exchange KSE Kernel Scheduler Entities KSE Kill Switch Engage (band) KSE Kuat Systems Engineering (Star Wars) . and others. "Factors Associated with Physician Involvement in Care Management." Med.Care. 39(7): 79-91, 2001. Barbara A. Niedz, PhD, RN is assistant vice president of quality outcomes at St. Joseph's Regional Medical Center. [ILLUSTRATION OMITTED] Richard B. Birrer, MD, is interim president and CEO (1) (Chief Executive Officer) The highest individual in command of an organization. Typically the president of the company, the CEO reports to the Chairman of the Board. , St. Joseph's Regional Medical Center, Paterson, NJ. He can be reached by phone at 973-754-4366 or by e-mail at birrerr@sjhmc.org. Dorathy Perez, RN, is director of care management at St. Joseph's Regional Medical Center. Anthony A. Losardo, MD, FACC FACC Fellow, American College of Cardiology , is director of clinical resource management at St. Joseph's Regional Medical Center. Colleen col·leen n. An Irish girl. [Irish Gaelic cailín, diminutive of caile, girl, from Old Irish. Matthews, MPA MPA medroxyprogesterone acetate. , RN, is vice president of managed care at St. Joseph's Regional Medical Center. By Richard B. Birrer, MD, Barbara A. Niedz, PhD, RN, Colleen Matthews, MPA, RN, Dorathy Perez, RN, Anthony A. Losardo, MD, FACC |
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