Making the "Shift" Away from Traditional Screening Criteria

Chesapeake Regional Healthcare, Chesapeake, Virginia

ChesapeakeHealth_Hospital-Profile

The XSOLIS tool is driving tremendous efficiency for my staff... Efficient UR RNs have gained 2 hours per day and normal/moderately efficient RNs have gained 1.25 hours per day with the use of XSOLIS...

-Jan Trevillian, Director of Care Management

Chesapeake Regional Medical Center (CRMC), a 310-bed facility that is part of the Chesapeake Regional Healthcare group, is passionate about caring for the people of southeast Virginia and northeast North Carolina. A local, independent, community-focused organization, CRMC is focused on delivering the highest quality and most technologically advanced health care to its community.

Challenge

Like many other hospitals, increasing pressures from audits and denials combined with changing regulations and the overload caused by disparate data sources posed respectively significant challenges for CRMC. Case and utilization management processes have not been quick to address growing data silos and technological barriers created by electronic medical records (EMRs). CRMC’s Director of Care Management, Jan Trevillian, sought to tackle these challenges proactively as the responsibility of her team grew to include transitions of care, referrals to hospice or palliative care, referrals to home health, discharge planning placement, case facilitation and utilization review.

Initially, Utilization Review (UR) and case management processes were extremely manual. With the reduction of paper charts through EMR utilization, skilled nursing staff was required to sift through piles of data and multiple systems to access critical patient information. Furthermore, these systems did not provide a continual stream of data that would allow staff to consistently analyze each patient’s condition in real-time or trigger automatic notifications as patient conditions change. This manual review process created inconsistencies in UR and case management processes.

Solution

Searching for a solution that would help streamline CRMC’s UR processes, Trevillian discovered that XSOLIS offered the first and only tool, CORTEX, that analyzes and scores clinical, administrative and financial data together in real-time to provide automated decision support for the level of care decisions, reimbursement accuracy and denial management. Trevillian opened initial discussions with XSOLIS and realized her opportunity to capitalize on the discrete data in CRMC’s EMR while also providing her team with a powerful tool for case review. In short order, CORTEX was implemented at CRMC to provide automated concurrent compliance monitoring on all patients all of the time and prevent claim denials at the point of care.

“There has not been a tool developed in over ten years that helps the Care Management/ UR process the way that CORTEX does,” says Trevillian. Through CORTEX, the Chesapeake team now has an automated flow of data that finds and highlights the key information needed for clinical decisions. CORTEX’s customizable dashboards and patient queues also help Trevillian’s team with workflow prioritization. Patient conditions that affect clinical decisions often change radically and rapidly - the Chesapeake team now utilizes XSOLIS dashboards to automatically identify patients in need of review based on changes in their condition. 90% of manual UR processes that involved sifting through medical records was eliminated, freeing up precious time for working with patients and families on transitions of care or discharge planning. The CRMC UR/Case Management team transformed from reactive to proactive and now spends more time on the medical, rather than the manual.

Results

Within days of implementing CORTEX, the Chesapeake team realized significant results. In the first few weeks, CORTEX’s proprietary analytics identified numerous patients where appropriate level of care was different from the actual patient status. Based on this insight, CRMC’s team took action to either place the patient in the appropriate level of care or obtain documentation to support the original assigned level of care.

The system makes it very easy to see where the patient is in their hospital stay progression and is a great resource to be able to glance quickly at issues that are driving inpatient status or observation status.

-Christina Fitzgerald, RN Case Manager, CRMC

This included patients who were reviewed in the morning and placed in observation status but due to subsequent changes in their condition, they met inpatient admission criteria. CORTEX automatically flagged relevant changes and triggered review notifications, resulting in status corrections.

Christina Fitzgerald, an RN Case Manager at Chesapeake, acknowledges CORTEX’s value in utilization review. She stated, “The system makes it very easy to see where the patient is in their hospital stay progression and is a great resource to be able to glance quickly at issues that are driving inpatient status or observation status.” Based on time studies before and after CORTEX, Fitzgerald reduced her own manual UR processes from five hours per day to three hours per day. Through the first five months of utilizing CORTEX, CRMC’s observation rate decreased 7.3% while concurrent denials decreased 59%.

Since going live with XSOLIS, CRMC now exclusively uses CORTEX for medical necessity screening, foregoing traditional screening tools. Additionally, CRMC is connected to Humana through CORTEX's payer-connected framework, giving payer staff analytics and access to approve member status determinations. By utilizing CORTEX to streamline processes, unlock the power of patient data, and proactively prevent denials, CRMC’s Case Management team focuses on what they do best: providing optimal care for each and every patient.

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Shift Moving Beyond Traditional Criteria

 

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