Rikki Moye doesn’t take things as they are. When entering her leadership role at Hillcrest HealthCare, Rikki knew she would face the same problems that plague care management across the industry: unstructured data that is difficult to harness, gaps in compliance data, lack of consistency or education or supervision, and most impactfully, no way to prioritize the work that has the most significant downstream impact. Rikki vowed to take a different approach. “[This role] was full of opportunities. I was brought in to build a model. To build a platform. To paint the picture the way we intended… and that began our journey,” she shared recently.
A premier regional health system, Hillcrest HealthCare represents eight major hospitals in the Tulsa, Oklahoma market with over 1,200 licensed beds across the system. That type of scale poses even more significant challenges: as Vice President of Care Management, how could she set up a system in which patients came first and processes were designed to serve them best?
Rikki’s spark came in a flash: instead of siloed utilization review, care coordination and discharge planning functions that sat side by side within the organization, what might happen if that model tipped on its side ? “When I put my head on my desk
in frustration, that’s when I realized that we were looking at things in the wrong way,” said Rikki. “That’s when I realized that utilization review needed to be a top-down view [of the patient], not a side view or worse, a blind[ed] view.” With utilization review at the top of the model, an RN Resource Manager could oversee the efficient use of resources for each patient as they progressed through their stay. Social work and care coordination would work hand in hand to manage the patient safely and efficiently, with a seamless discharge handoff.
This model – dubbed the Right Care Case Management Model – encompasses five “rights”: the right patient, care, setting, documentation, and billing/payment. “We borrowed from nursing services to create this framework,” said Rikki. “What you see in this hourglass model is the resource manager overseeing this efficient use. If you can imagine sand through an hourglass, that’s the patient’s journey – supported and guided at all times from various members of the care team.”
In normal circumstances, adopting the Right Care Model would be near impossible – the labor required is too great, the quantity of data needed is too vast, consistency and leadership at scale is hard to achieve. But Rikki had been a long-time advocate of CORTEX, the technology system built to address those challenges and allow clinical staff to refocus their efforts on the patient, not administrative work.
Rikki and her leadership gathered support for an XSOLIS partnership and took CORTEX live at seven Hillcrest facilities in mid-2020. With CORTEX, her staff could now access a real-time, AI-driven view of each patient’s medical necessity, prioritize cases by revenue sensitivity and risk, and use CORTEX as a communication channel for their payers. Indeed, several payer partners, including Humana, also now use CORTEX to concurrently review and approve member cases.
Within the CORTEX rollout, Rikki engaged teams across the organization: nursing managers use CORTEX multiple times a day to determine discharge readiness and review records; hospitalists are trained to utilize reports during huddles; ED case managers eye CORTEX throughout their shift to gauge proper admissions and status decisions. As Rikki has stated, “the Right Care Model is constantly evolving, so our use of CORTEX needs to expand” with it.
Even with these outcomes, the Hillcrest team is not standing still. In Rikki’s words, “we are always pushing towards the future. As healthcare reforms and these things change, if we are not ahead of the curve, then we are going to be left behind.” She continues, “the Right Care Model may not work for everyone. But you can adjust and modify to fit your needs and to fit the needs of your patients. Innovation starts somewhere, and it starts with you.”
The right patient, care, setting, documentation and billing/payment.
To hear from Rikki Moye how she created the Right Care Case Management Model, fill out the form below and receive access to the on-demand webinar: