The Mentor® Model: care management in the 21st century - Patient Care

Physician Executive, Jan-Feb, 2004 by Richard B. Birrer, Barbara A. Niedz, Colleen Matthews, Dorathy Perez, Anthony A. Losardo

Quality of care has become increasingly important over the last three decades, driven by the growth of managed care, increased customer expectations, changing demographics, intensified governmental regulation, the Balanced Budget Act and the Leapfrog Initiative. (1)

New technologies and pharmaceuticals, coupled with the aging population, exert further pressure on providers to utilize costly resources in the most efficacious manner. With respect to inpatient care adjusted length of stay (ALOS), denials management and utilization management (UM) have grown to bellwether status for health care organizations tracking performance. (2)

Case management, whether hospital-based, community-based or hospital-to-community, quickly became the panacea addressing many of these issues and met with some success. However, many of its deliverables (streamlining discharges, controlling costs and reducing denied days) distanced the physician from involvement and best practices. (3,4)

Traditional case management evolved to meet these changing standards and challenges. (5) Criteria were adopted, policies and procedures developed and physician behavior targeted. The number of clinical guidelines and protocols increased exponentially.

There was a shift from a financially driven model to a clinically aligned one. Demand and disease management programs were developed, and case management was transformed into care management under a continuous quality improvement umbrella. (6-10)

The pivotal role of the physician in the process, however, is under-appreciated and under-leveraged. (11-13)

To address this problem, a new program known as the Mentor[R] Model (Multidisciplinary Excellence, Nurturing Teamwork, for Optimal Resources) was developed by hospital leaders and the clinical staff at St. Joseph's Regional Medical Center in Paterson, N.J.

Nurses, administrators and physicians retooled a traditional case management program that was led by nurses, based on financial deliverables and linked case managers to individual physicians.

FIRMing up the process

The new model of care management involves a system called FIRM (Floor Initiated Resource Management) that was put into place on each patient care floor.

FIRM teams are led by physicians (employed or community-based) and also include a care manager, clinical social worker, nursing unit manager, resident physicians and miscellaneous personnel (students, pharmacists, administrators, ethicists, etc.) who work together to manage patient care.

Another key element to the mentoring model is PURR (Physician Utilization Resource Recovery). Through PURR, the number and type of laboratory, radiologic, imaging studies and pharmacotherapeutics are tracked for each physician and compared to an institutional peer group by specialty. Monthly meetings are held for the FIRM and PURR teams during which performance data are reviewed, challenges identified and problems addressed.

On a daily basis, another team called WARR (Winning Admissions and Recovering Rejections) meets to review concurrent denials. The group also looks at admissions, guidelines, practice patterns of attending physicians and residents, operational efficiency, bed management and managed care.

Physician practice issues are handled on a one-to-one basis. If a patient's care plan is problematic (fails to meet diagnostic criteria or involves inappropriate tests, delays in results or consults) the FIRM attending calls and speaks directly to the private medical attending (PMA).

The discussion is one of mentorship based on best practices and is never punitive. Guidelines or clinical practice protocols are used in a coaching framework. This is done because studies suggest that physicians respond more favorably to new information concerning quality of care or cost when another physician--particularly one in a clinical leadership position--communicates the message.

If the FIRM leader is unable to modify bedside behavior, the chief/director of the service, the chairman of the department and chief medical officer are notified.

Testing the model

With the mentoring model in place, a study was conducted at St. Joseph's, a 780-bed inner city tertiary care hospital, from April 2001 to August 2002 to see how mentoring was affecting patient care.

The study was based on data from ALOS, denials, guideline compliance, recovered days and physician utilization profiles. There were 27,025 patient stays measured in the 2001-2002 dataset, and 28,321 patient stays measured in the 2000 to 2001 dataset.

Of these, the Medicare patient stays numbered 6,834 in 2001-2002, and 7,269 in 2000-2001. Guidelines, including standing orders for the top 25 drug related groups (DRGs), were developed through nurse-physician collaboration.

The most dramatic changes occurred in length of stay. Prior to the initiation of the daily concurrent denials review process (in August, 2001) and the FIRM process (Nov, 2001) the overall length of stay averaged 5.8 days; some months saw spikes at 6.65 days, 6.14 days.

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