Taking A More Thoughtful and Evidence-Based Approach to Utilization Review

Carle Health

Carle Health

Carle Health’s results from utilizing the Xsolis platform aren’t just quantitative. According to Carle Health, partnering with Xsolis “gives nurses a chance to be nurses.”

When Amy Bandy, Director of IP Clinical Case Management, joined the Carle Health Case Management and Utilization Management organization in July 2020, she realized her team wasn’t utilizing the Xsolis platform to its full potential. While helping her team implement the Xsolis platform in the Spring of 2021, Brandie Anderton, Director of Case Management, also realized Carle Health needed to utilize the platform more effectively. Together, Amy and Brandie enhanced their teams’ use of the platform which led to utilization management workflow optimization, a significant decrease in their nurses’ administrative burden, the ability to track their team’s productivity, and insights from other reporting capabilities.

Shifting Away from Traditional Criteria

As part of their mandate to make the utilization management workflows as efficient, standardized, and objective as possible, Brandie and Amy recognized that their teams needed to shift from traditional criteria and instead use the Care Level Score™ (CLS™) to determine appropriate statuses. Since their teams implemented that change in March 2022, they haven’t looked back.

“Traditional guidelines were too narrow,” Brandie stated. “We needed a more global view of everything that contributes to a patient’s hospitalization, which is a key component of what makes Xsolis a leader in this space.” This shift has allowed Carle Health’s nurses to focus on what matters most: ensuring each patient gets the care they need. 

“I believe with my whole heart that the Dragonfly Utilize [CORTEX. UR], approach gives nurses a chance to be nurses and complete assessments, create plans, and do reassessments and evaluations. They can feel like they’re advocating for their patients with payers to make sure reimbursement for the wonderful care provided is appropriate.”

– Brandie Anderton, Director of Case Management

Employing the Care Level Score (CLS) to Decrease Their Exception Rate

The next step involved working to align their key performance metrics, so they were applying the Care Level Score™ (CLS™) in alignment with the CMS Two-Midnight Rule. Carle Health now uses the CLS, length of stay, and clinical merit of the case to drive status determination ensuring that each patient’s care is not only evaluated instantaneously based on the full spectrum of patient data but is also evidence-based. This allows the Carle Health utilization review (UR) nurses to shift their focus to cases that need their attention in real-time.

According to Amy and Brandie, their teams are performing much better now than they were in late 2021/early 2022, especially because they’re truly engaging in the XSOLIS workflows and the CLS as well as ensuring all team members use the platform. This alignment and engagement led to a 15% decrease in the exception rate from 2021 to 2022. The exception rate is an Xsolis-specific metric which identifies observation discharges with a length of stay 2+ midnights and a Max Care Level Score >75, indicating potential missed opportunities for conversion.  

Implementing Best Practices with the Xsolis Clinical Engagement Team

In November 2021, an XSOLIS clinical engagement consultant (CEC) was assigned as a clinical partner to Carle Health to provide continuous measurement of workflows, performance metrics, and fiscal impact to drive actionable change. The assigned CEC performed clinical audits in late 2021 and early 2022 to identify opportunities for potential inpatient conversion and ensure proper application of the CLS, the clinical merit of cases, and when appropriate, the CMS Two Midnight Rule. Additionally, in alignment with Carle Health’s shift from traditional criteria, the CEC provided training to standardize the review process and decrease variation between the UR nurses. In June 2022 Carle Health implemented clinical nurse rounds where analytics of individual case examples are used to coach and educate nurses on the CLS, machine learning, and clinical workflow optimization.

Helping Carle Health’s Nurses and Physician Advisors Perform At the Top of Their Licenses

With Xsolis, Carle Health can ensure that the work of their physician advisors (PAs) is consistent by allowing their team to review outcomes, documentation, and productivity. Additionally, Xsolis data has been used by Carle Health to educate their PAs and nursing staff. According to Amy, “Xsolis enables consistent communication between the UR nurse and the physician advisor, which allows us to follow each case from start to finish.” In addition to providing support to Carle Health’s physician advisors and nurses, Xsolis has also helped the team establish and transition to a fully internal PA system.

Utilizing Actionable Reporting and Analytics

Carle Health utilizes reporting in the Xsolis platform to track nursing productivity and engagement, specifically using the tool to identify key areas for improvement and associated metrics. hey then use this information to help them establish a plan to reach those metrics. Nurses get weekly reports on their productivity as well as reporting on other metrics like their observation rate. Carle Health understands that frontline staff are more engaged when they can see how they’re progressing towards their goals and the Xsolis platform has been instrumental in this aspect. Reporting through the platform has also helped them to understand the appropriate questions to ask to ensure they are getting the best outcomes.

“Leadership and management know what to look at now and the right questions to ask. Dragonfly Utilize [CORTEX.UR] has allowed me to have that knowledge right at my fingertips.”

– Amy Bandy, Director of IP Clinical Case Management

Although both Brandie and Amy agree that the biggest benefit of the Xsolis platform is that it allows their “nurses to be nurses” and practice at the top of their licensure, Carle Health has also experienced a significant ROI since partnering with Xsolis.



ROI projections are estimates based on similar system information and averages over the first 2 years of utilization. Such ROI projections do not guarantee future results. Actual ROI will vary based on various conditions and factors for each customer, including, but not limited to, client baseline information, best practice utilization of the products, etc.