InterQual Case Study - Florida Hospital Orlando
Florida Hospital Orlando, a member of the 10-state Adventist Health System (AHS), is a 1,217 bed acute-care community hospital. AHS’s Population Health Services Organization (Florida Division) was formed to guide the adoption of transformative, value-based, integrated health care models.
The Challenge: Overutilization in the ED and Inpatient Overcapacity
In a move toward a more strategic value-based model, the Population Health Services Organization (PHSO) began looking across its hospital network for opportunities to improve care decisions and efficiency. Eugene Truchelut, M.D., Medical Director of Clinical Performance at the PHSO, and his group investigated overutilization and improvements for more appropriate care management in the Emergency Department (ED) at Florida Hospital Orlando. The hospital was experiencing an increasingly busy ED and was regularly 5-10% overcapacity in inpatient care.
In 2015, the hospital's ED saw more than 114,000 patients and the hospital had more than 50,000 admissions.
"When I started out with Florida Hospital Orlando, being at overcapacity was something that only happened occasionally in the wintertime when the snowbirds were here. But, over time, it became a more frequent occurrence," recalls Dr. Truchelut
He and the multi-disciplinary Performance Review Committee ran two pilot programs to address the overcapacity situation at Florida Hospital Orlando, and evaluate the role of care management in the emergency department and the observation settings.
The Solution: Creating New Processes for Observation Stay and Collaborative Case Management
The first pilot program was designed to achieve better congruence between what the evidencebased criteria indicated was the appropriate level of care for a particular patient and what actually happened. Primarily, the decision in question was between inpatient and observation. Over four weeks, during daytime hours, the Committee had six observation beds reserved for a "Sta-Obz" pilot for patients of one hospitalist group. Patients with questionable level-of-care admissions were temporarily assigned to an observation bed — instead of being admitted as an inpatient — to give the case managers and physicians enough time to gather needed information to determine the appropriate level of care.
The standard procedure for addressing those cases was to notify the case manager to come down to the ED and assess the patient for admission using InterQual®. This traditional process took time and often meant that the completion of the medical review came after the admissions decision had been made.
Over the month-long pilot program, 105 patients were placed in the special "Sta-Obz" unit; under the traditional system they all would likely have been admitted as inpatients. Ultimately, 73 patients (69%) were discharged from this observation unit and only one was subsequently readmitted. This resulted in an estimated 255.5 inpatient bed days saved and estimated corresponding cost savings of $204,400 for the hospital.
The goal of the second pilot was to divert unnecessary admissions by getting the case managers and social workers involved at the very beginning of the encounter. The scope of this project was four months. Although it started out as only part of the day, it didn't take long to see the positive results, and so was changed very quickly to a 24-hour-per-day coverage with the case manager.
"The case managers weren't really getting into the ED and being part of the team in order to expedite things. We decided to assign an RN case manager and social worker to collaborate in real time with the ED physician. They would be a part of the ED team assigned to the physician and would assist in managing the level of care, rather than coming in as a consultant after the fact," says Dr. Truchelut.
With the new team approach, the case manager shadowed the physician as the patient was interviewed and the evaluation began. And just as the doctor started their process of determining what this patient needs, so did the case manager.
The case manager would discuss their findings, the plan of care and medical necessity (based on InterQual Criteria) with the team. At the same time, durable medical equipment, medication and social needs could be identified. Very often, these nonmedical issues lead to unnecessary admissions. To prepare patients for when they left the ED, the hospital would connect them with community resources via faster referral and coordinate their care in the outpatient setting.
Being able to leverage the evidence-based criteria was foundational in decision making, according to Dr. Truchelut. It helped ensure that the decisions about patient status when leaving the ED were correct — whether to admit, and if so as inpatient or observation.
"The value of InterQual is pretty clear. It was integral to our process. It was 100% accurate for avoided admissions. And it selected people on the right path to admission," states Dr. Truchelut.
The Results: Retrospective Review Confirms Appropriateness of Care
Dr. Truchelut and an external review team at the PHSO retrospectively tracked the admissions avoided, and the cases quickly accumulated. It soon became apparent that they needed to understand and categorize the results. The team, composed of clinicians experienced in inpatient utilization management, audited all avoided admissions using InterQual Acute Criteria to make an objective determination of whether the level of care was applied correctly.
"It was valuable to go back and conduct an independent, secondary review to confirm that all of those who were not admitted should not have been," says Dr. Truchelut. "The InterQual criteria helps us verify that each patient receives the appropriate level of care."
In fact, they found that the process helped staff determine the most appropriate course for a particular patient. Patients not meeting hospital level of care were referred quickly to the appropriate community resources by a hospital social worker or nurse care manager. Patients who were discharged were placed in more appropriate care settings, including assisted living facilities, skilled nursing facilities, hospice, behavioral health facilities and even a home setting with appropriate support.
The results of the pilot were striking. There were 98 patients with avoidable admissions, none of which met InterQual Acute Criteria for either observation or inpatient, yet all were on a path to inpatient admission before the process was applied. The hospital saved an estimated 343 bed days in 15 weeks, which led to an estimated cost savings of more than $274,000, before including the cost of ancillary services, provider charges and the cost of appeals.
Extending Collaborative Case Management to Imaging
The ED pilot also uncovered that some patients had numerous imaging scans within a relatively short period of time. For example, one patient had received three CT scans of the same type in two months, while another patient had seven Abdominal/ Pelvis CT Scans in three months. Florida Hospital Orlando plans to expand its auditing program to cover imaging studies, using InterQual Imaging Criteria, to establish medical necessity. The aim of the new program is to help avoid unnecessary scans and duplicative testing.
"This is a brave new world of utilization management in the hospital," suggests Dr. Truchelut. "It is simply not sustainable to overutilize complex imaging. We need to take a hard look at this, and really at the utilization of all high expense items and services. There has to be a culture change in how we operate in the future."
Growing Impact on Hospital and Community
The Florida Hospital Orlando administration has welcomed the results of the initial pilots and funded the project to continue, according to Dr. Truchelut. The company is hiring full-time employees to continue its observation-stay program. The ED collaboration with the ED team of clinicians and case managers will also continue.
In addition, both pilot programs were well received by the community at large.
"Patients who were sent to the ED by their physicians with the expectation that they would admit them were grateful that the admission had been avoided," reports Dr. Truchelut. "Physicians were happy not to have the patient get inappropriately admitted. The patient's need was met. The caregiver's need was met. Improving inpatient utilization is for the good of everyone — ultimately it's for the good of the community."