1. Owen, Mindy RN, CCRN, CCM
  2. Gentry, Dawn MSN, RN, CCM

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It is only through collaboration that we will improve patient care and outcomes. As we move toward increasing services and care being provided within the community, it is our responsibility and challenge to build collaborative initiatives to meet the needs of our patients, our health systems, and our communities. I am pleased to share with you a collaboration in Virginia that is doing just that: enhancing the care for the "at-risk" population it serves and showing us an innovative approach to both clinical and fiscal responsibility.


It is my pleasure to introduce to you, Dawn Gentry, MSN, RN, CCM, Director of Inpatient Care Management at Carilion Roanoke Memorial Hospital. Dawn has been the director of the department for 5 years and was a member of the staff prior to her current position. It has been under her leadership and direction that this collaboration has developed, and I am glad to provide Dawn an opportunity to highlight the initiative in this column.


Mindy Owen


Four years ago, we found ourselves struggling with a large volume of unfunded patients with post-acute discharge needs. This ranged from the need to obtain medications in order to support a comprehensive transition of care plan to requirements for patients who would benefit from long-term care placement. With 703 licensed beds in Carilion Roanoke Memorial Hospital, we are a regional referral center in Southwest Virginia that needed to improve throughput and outcomes regarding transitions of care. And as a Level 1 trauma center with multiple specialty care areas, the needs extended beyond our local community to other areas within Virginia and beyond to border states. This was a tremendous source of stress and concern for our Care Management department that felt the pressure daily to improve this dilemma. The issue began a conversation where we asked:


* What can we do?


* What viable solutions may be out there that we have not explored?


* What community partnerships could we engage in to develop a solution?


* How can we advocate for this "at-risk" population that has post-acute care plan interventions that are not being met because of lack of a funding resource?


We began to look at viable solutions with a community partner to help fill this need.


We researched literature, benchmarked with peer facilities, and held numerous meetings with community organizations. Our own internal data and information from our local community needs assessment survey were examined. Through this process, we gained valuable knowledge, insight, and relationships to help ensure the patients who we had the privilege to care for could transition outside our walls a little easier. This brought comfort to patients and families-and to our own staff as well. The Care Management team began to see that working together with the community broadened everyone's perspective. And it opened up ideas that, in the past, may not have been considered or explored.


Our efforts resulted in the beginning of some creative partnerships. One of the new collaborations was with our local DSS (Department, Social Services) office. Through those efforts, we developed a cost-sharing plan to hire and position in the Care Management department an "Outstationed" Eligibility Worker (OEW) position. This was the first time that a DSS employee would be positioned within the hospital, with reporting responsibilities to both DSS and the hospital. The expenses, as well as the outcomes, are shared.


Initial efforts were focused on patients needing funding for long-term care. Funding for long-term care beds were the largest portion of our external avoidable days. Our internal Eligibility Assistance Services team works to complete the Medicaid application and obtain needed verifications from patients and families. Our OEW is able to continue work on the verifications and overall process and time frame. They can then enroll eligible patients, deny the application, or work the application up and send it to the identified locality to complete processing.


Through the collaborative efforts, the wait time for our patients needing Medicaid for long-term care placement has decreased from an average of 45 days to an average of 22 days. This is a benefit for the patient and family by getting the patient to the right setting of care in a more expeditious manner, as well as benefitting the hospital in improving the throughput process.


As we have seen a dual benefit when the OEW assists with patients needing long-term care placement, we have included patients with other post-acute needs such as outpatient dialysis to the list of patients who may benefit from this collaboration.


The next step we have taken is to engage DSS in our risk-sharing process, as we await approval for funding. This has helped progress patients to the most appropriate level of care while minimizing risk to the organization. In FY 2016, of seven potential risk-sharing agreements totaling $147,000 for hemodialysis, Medicaid has approved payment retroactively in all cases, with no financial obligation to the organization. The OEW is able to enroll patients in Medicaid for their own jurisdiction and for several other contiguous counties as well. We are looking to expand the counties eligible for enrollment this year as we present the positive data and outcomes to show a "win-win" for everyone involved. The data prove how beneficial the collaboration can be financially; meanwhile, the hard-to-measure outcomes such as improved communication, improved job satisfaction, and relationship building are all important and have seen a vast improvement. This has been documented through employee surveys and anecdotal information.


Although they are not able to assist every patient, this has been a key initiative for us. The partnership has grown and developed over the past 4 years. We currently have two full-time cost-shared positions and plan to add two more this coming year. Having the OEW position has been beneficial to our patients and their families. Having the OEW has reduced the time demands and potential hassles to our patients and their families involved in going to a local office to apply for health care coverage. This allows the focus to remain on healing and ensures that necessary follow-up care is available, thus improving the health of the community.


The OEW position has benefitted our facility by decreasing the time between the identified need and enrollment in a public health care program. This decrease in time allows patients to transition more quickly to the next level of care, freeing valuable beds to care for other patients in the community. Payments for Medicaid reimbursements can be retroactive. This eases the burden of care on our not-for-profit and allows those financial resources to be used for further patient care and support of the health of our community.


We are able to assist an "at-risk population" gain access to the right resources and the right place of care to meet their needs in a reduced time frame. This has been a big satisfier for our staff as they advocate for our patients. Serving as patient advocates is one of the many reasons why we all love the work that we do.


It is the heart of case management.