GETTING IT RIGHT FROM THE START:
Emergency Department Admission Classification for
Medicare Patients
Building the Bridge:
Excellence through Innovation, Education and Financial Stewardship
Grand Hyatt Hotel
October 27, 2011
Team Members
Sponsor:
• Dr. Sandra Murdock
MD Champs:
• Dr. William Mileski
• Dr. Parham Parto
Team Members:
• Kathy Nash, NP
• Andrea Sunday, RN
• Laurie Popovits, RN
• Samantha McBroom, RN
• Jamie West , CM
Team Leader:
• Annette Macias-Hoag, RN
Ad Hoc Team Members:
• Virginia Morales- Care Management
• Melinda Tillman- ED Nursing
Informatics
• Jennifer Zirkle- Care Management
Facilitators:
• Gina Butler, RN
• Angel Male, RN
Aim Statement
To decrease the percentage of Medicare patients admitted
from the Emergency Department classified as full
admission status, with a length of stay <24 hours, from
7.5% to 2% by June 30th, 2011.
Background
Why did we focus on Medicare
patient admissions?
In August 1, 2008 a Zone
Program Integrity
Contractors (ZPIC)
revealed an overpayment
claim of approximately 1
million dollars from our
institution
4
Background Data
•Admission vs. Observation classification status was
recognized by hospital leadership as an opportunity for
improvement.
•Scope was narrowed to Internal Medicine Admissions
(Medicare) that had a length of stay (LOS) less than 24
hours.
•About 31% of patients at UTMB are admitted through the
Emergency Department.
•Currently, 7.5% of Internal Medicine Admissions
(Medicare) had a length of stay (LOS) less than 24 hours.
5
Performance Measures
•Full Admits with LOS < 24 hrs
• Intervention 1 (Care Management)
• Intervention 2 (Hospitalist Consult)
• Intervention 3 (Education) Implemented Post Graduation
•Data Source: EPIC EMR / Invision
FY 2011
CL
1/1
UCL
12/25
12/18
12/11
12/4
11/27
11/20
11/13
11/6
10/30
10/23
10/16
10/9
10/2
9/25
9/18
9/11
9/4
LOS < 24 Hours
Baseline Data: 09/10 to 01/11
35%
30%
27.6%
25%
Pre-Intervention
20%
15%
10%
7.5%
5%
0%
Process Analysis
•Brainstorming
•Process Flow Mapping
•Cause and Effect Diagram (Ishikawa)
•Pareto Chart
Process Flow of Admissions from the ED
Cause and Effect Diagram
Pre Intervention Data – Pareto Chart
Medicare Full Admissions
September 1, 2010 - February 6, 2011
96.3%
25
90%
85.2%
LOS <24 Hours
100%
20
80%
74.1%
70%
63.0%
60%
15
50%
48.1%
40%
10
33.3%
30%
20%
5
10%
0
0%
Tuesday
Sunday
Wednesday
Monday
Thursday
Saturday
Friday
Working Towards Improvement
• Care Manager stationed in the Emergency
Department for 4 hours a day, Monday
through Friday
• Hospitalist Consultation for Emergency
Department patients requiring possible
admission Monday through Friday from 8am
to 9pm
• Education to Emergency Department
Providers provided during staff meetings
• Education to residents at noon conference
30%
UCL
CL
7.5%
5%
FY2011
2/11
2/18
2/25
3/4
3/11
3/18
3/25
4/1
4/8
4/15
4/22
4/29
5/6
5/13
5/20
5/28
6/4
6/12
6/18
6/25
35%
Pre-Intervention
1/8
1/15
1/22
1/29
2/5
9/4
9/11
9/18
9/25
10/2
10/9
10/16
10/23
10/30
11/6
11/13
11/20
11/27
12/4
12/11
12/18
12/25
1/1
LOS<24 hours
Results: Overall Interventions
Intervention 1
Care Management
Intervention 2
Hospitalist Consults
27.6%
28.9%
25%
20%
20.6%
15%
10%
6.9%
3.5%
0%
Intervention #3: Reference Card
Referenced from New Mexico Medical Review Association
Results: Post CS&E Graduation
Beginning of new resident
rotation through the
Emergency Department
30%
Interventions #2 & #3
(Hospitalist Consults & Reference Cards)
20%
Hospital was on diversion
-approx. 30 patients
waiting for a bed
15%
10%
5%
UCL
9/24/2011
9/17/2011
9/10/2011
9/3/2011
8/27/2011
8/20/2011
8/6/2011
7/30/2011
7/23/2011
7/16/2011
7/9/2011
8/13/2011
FY2011
10/1/2011
0.02
0.00
CL
0%
7/2/2011
LOS <24 Hours
25%
Return on Investment
Full Admission Error
Projected Cases
Reduction in cases/yr
Overbilling/case
Overbilling/yr
ZPIC Audit
Avoidance/yr
7.5%
62
$
$
$
28
10,800.00
302,400.00
30,240.00
4.1%
34
Return on Investment
Year 0
Costs
Year 1
Year 2
Year 3
$ 30,240
$ 30,240
$ 30,240
$ (28,283)
Benefits
Cost of Capital
9%
ROI
220.76%
NPV
$48,263
Next Steps
• Monitor for improvement
• Full Time Care Managers
• 24/7 Hospitalist coverage
• Education
• Focus efforts on observation cases
Lessons Learned
•
Leadership involvement and support
•
Staff ownership
•
Understanding of time commitment
Questions???