The Agency for Healthcare Research and Quality
3 defines patient safety practice as “a type of process or structure whose application reduces the probability of adverse events resulting from exposure to the health care system across a range of diseases and procedures.” Health care accreditation organizations share the concern about patient safety and are now endorsing patient safety practices. URAC is a national nonprofit health care accreditation organization. In January 2006, URAC announced revisions to their standards for quality management, including new requirements for ongoing patient safety initiatives. Case management (CM) and health utilization management are among the accreditation programs affected.
Today's case managers are challenged with promoting quality health care and optimal clinical outcomes while reducing costs in a health care system that is fragmented and overburdened. This is especially true for case managers who are employed in managed care and never more important than in a third-party administrator (TPA) practice setting. Insurers and employers alike are beginning to revisit strategies to contain costs resulting from recent increases in insurance premiums coupled with slower economic growth.4 With a renewed focus on cost containment, small to mid-sized self-funded employers depend on CM to coordinate quality services, enhance the employee's satisfaction with their health benefits, and demonstrate outcomes that parallel that of regional and national carriers.
Local and regional TPAs typically do not credential and maintain their own network of providers and facilities. Instead, an employer group that contracts with a TPA to administer their health plan accesses a provider network and discounted fee schedule by contracting with a separate preferred provider organization (PPO) that works in partnership with the TPA. Tracking and trending individual provider quality and performance and procedural training is performed by the PPO and is not necessarily shared with their TPA partners. Although a case manager certainly collaborates and communicates with the patient's health care providers, a separate provider network makes it a challenge for the case manager to impact overall quality outcomes when there is little or no access to or influence on an external provider network.
Although the health care system is responding to the demand for safe patient care, safety issues still are often identified after the fact. If an urgent patient safety issue presents to the case manager, as an advocate he or she can always intervene with the provider on behalf of the member or request the assistance of higher-level management or a physician advisor, if necessary. Otherwise, at best a case manager working in a TPA practice setting can report a patient safety issue or adverse outcome involving a network provider to the PPO and hope that it is received, reviewed, addressed, and tracked.
The Case Management Society of America5 defines CM as “a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes.” Advocating for the individual's health needs by promoting patient safety clearly falls within the scope of the case manager's responsibility. Tahan suggests that one of the five main areas where case managers can enhance patient safety is through patient and caregiver education aimed at empowering patient self-management and compliance with the medical treatment plan.
Discharge planning is another important CM function with patient safety implications. Proactive and careful discharge planning can significantly improve patient outcomes and is most effective when initiated at the time an admission is identified. Through careful assessment, monitoring, planning, educating, and communicating, case managers can empower their patients and not only promote patient safety but also help prevent and anticipate problems.
The purpose of this article is to present an approach for proactively managing planned elective hospitalizations. A focused patient safety educational intervention was developed and aimed at reducing readmissions due to avoidable complications while making individual plan participants aware of the availability of CM services.
Group Benefit Services, Inc., located in Hunt Valley, Maryland, is a national provider of employee benefits and health care administration. The CarePlus Care Management Department provides distinct utilization management, CM, and disease management services telephonically to plan participants of small to mid-sized self-funded employer groups. The Quality Management Committee (QMC) oversees the activities of the care management department, including monitoring performance and standard clinical indicators.
Unplanned readmission within 30 days of a hospital discharge is a standard quality indicator of a health plan's effectiveness. A retrospective study was conducted to examine unplanned readmissions within 30 days of discharge. Data from January 1, 2003, through December 31, 2003 were reviewed. After excluding readmissions related to preterm labor followed by delivery and psychiatric readmissions, a total of 2111 admissions fell within the period under review. The study demonstrated an unplanned readmission rate of 3.08% (η = 65). Further analysis demonstrated that of those unplanned readmissions, 48% (η = 31) took place within 30 days after the patient had been discharged from an elective admission. This finding is significant for case managers in a TPA practice setting where it is not possible to educate providers across a network and present an opportunity for a proactive patient safety educational intervention aimed at improving outcomes and decreasing unplanned readmissions after discharge from an elective admission.
After analysis of the baseline findings, an action plan was developed, presented to, and approved by the QMC. A goal of 15% or less of unplanned readmissions resulting after discharge from a planned elective admission was set. A new procedure was implemented so that care management support staff who verify that a planned inpatient admission actually took place also furnish the name, direct phone number, and secure fax number of the patient's case manager for the express purpose of initiating the discharge planning process. The CM team also participated in an educational presentation on proactive discharge planning, early identification of at-risk individuals, and prompt referral to CM when appropriate screening criteria are met. These elements also were integrated into the orientation program and tools used to audit individual case manager and support staff performance.
An item was placed in the CarePlus Bulletin (Vol. 2, No. 1) educating patients who are planning an elective admission to initiate the precertification process early. The bulletin is a value-added health and wellness newsletter with information and tips for more healthful living that is distributed to clients on a quarterly basis. Another item in the bulletin provided information about CM and how patients can access a case manager and self-refer to the program. Additionally, an article titled “Improving Patient Safety,” adapted from information available from the National Patient Safety Foundation, was included in this issue.
Additional research was conducted and a fact sheet from the National Patient Safety Foundation7 (Figure 1) was adapted into a safety-focused patient educational handout, Safety as You Go from Hospital to Home, which is mailed along with his or her precertification approval letter to every patient scheduled for an elective admission. This handout provides information to aid in preparing for a smooth transition from the hospital to home. It also provides information about the CM program, how a case manager might be able to help, and how to access a case manager and self-refer to the program.
Data were again reviewed, from January 1, 2004, through December 31, 2004, with a total of 1592 admissions. Readmissions related to preterm labor followed by delivery and psychiatric admissions were again excluded from the study. The findings demonstrated a readmission rate of 3.02% (η = 48) in 2004, a decline of 0.06% of the readmission rate. Of those readmissions, 37.5% (η = 18) were unplanned within 30 days after the patient had been discharged from an elective admission. These findings represented a decrease of 10.5% in unplanned readmissions within 30 days after the patient had been discharged from an elective admission.
The results from 2004 were promising. However, because the goal of 15% of readmissions that result after discharge from a planned elective admission was not met, the project remained ongoing. Proactive discharge planning procedures were reviewed with the staff. An additional intervention that was put into practice was the development and implementation of timely follow-up with all patients recently discharged from the hospital and not currently enrolled in CM. These “Hospital Discharge Follow Up” calls, made by case managers within a week of obtaining the individual's discharge date, allowed the patient direct access to a case manager and enabled screening and referral to CM for additional interventions, if needed.
Data were again analyzed, from January 1, 2005, through January 31, 2005, with mixed results. There were a total of 1318 admissions in the study period. The results demonstrated a readmission rate of 4.55% in 2005 (η = 60), an increase of 1.53% of unplanned readmissions within 30 days in the period under review. However, of those readmissions, 25% (η = 15) were unplanned readmissions within 30 days after the patient had been discharged from an elective admission. While the overall unplanned readmission rate did increase, the results demonstrated a 13% decrease in readmissions after discharge from an elective admission.
Additional measures aimed at improving the results included replacement in the bulletin (Vol. 4, No. 1) advising patients planning an elective admission to initiate the precertification process early. The article also included specific information about the Safety as You Go from Hospital to Home program. Another item that included information about CM and how patients can access a case manager and self-refer to the program was added. Using the National Patient Safety Awareness Week campaign coordinated by the National Patient Safety Foundation (March 5–11, 2006), the article ABCs of Patient Safety also was included in this volume. The CM team participated in a formal 1-hour continuing education presentation, Discharge Planning: Pearls and Pitfalls, to continue to promote the importance of discharge planning as an important CM intervention.
Patient safety will remain a top priority in health care. This study explored the effect of using a safety-focused patient educational intervention along with other outreach, educational, and screening measures over time to reduce readmissions after discharge from a planned elective hospitalization (Table 1). The results suggest that a patient intervention with a safety focus that is implemented ahead of a planned admission can help educate and empower patients and caregivers and improve outcomes by helping decrease unplanned readmissions after discharge from a planned elective admission (Table 2, Table 3). These findings will be of interest to case managers in a variety of practice settings, especially those working in a TPA practice who seek creative ways to impact quality and outcomes but have limited or no access to or influence on an external provider network.
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