CASE STUDY ON UTILIZATION REVIEW CASE B DEVELOPMENT OF A UTILIZATION REVIEW PLAN AND OTHER FUNCTIONS REQUIRED OF A "PROVIDER OF SERVICE" Background Information: The Scottish House, Inc., a licensed 32-bed non-profit nursing home, offers medical-nursing care for the aged. The home is managed by a board of trustees comprised of interested citizens of Tiller County. Skilled nursing care is provided on a 24-hour basis. The nursing staff consists of four graduate nurses, four licensed practical nurses, five nurses' aides, and three orderlies. home is run by an administrator, an R. N., directly responsible to the Board of Trustees. The administrator of Scottish House wishes to develop a utilization review plan and other required functions toward qualifying Scottish House for participation as an extended care facility under Medicare. Since Scottish House does not have a formally constituted medical staff, the administrator had to seek resources for a utilization plan outside the facility. Her first action was to contact the executive secretary of the Tiller County Medical Society for suggestions and assistance. She learned that the Medical Society was currently studying alternatives for providing medical guidance to nursing homes in achieving certification, but that no specific plan had yet been implemented. The Society executive expressed willingness to assist in developing a utilization review plan for the nursing home facility, but said the Medical Society lacked experience in the area of utilization review for long-term care facilities. A meeting of the nursing home administrator and the Society executive with the physician-Director of the Medical Center (the large general hospital in Dixon) was arranged, to discuss the problem further. This meeting elicited the following information: 1. 2. 3. That a utilization review committee had been established at the Medical Center in anticipation of the Center being certified as an "approved provider of service" under Medicare. That this committee had already developed criteria and methods for sample review of admissions, duration of stay, and services provided, and for individual review of extended stay patients admitted to its 402 general hospital beds. That the committee was presently attempting to develop similar criteria for the Medical Center's 58-bed convalescent unit, in anticipation of seeking certification of this unit as an "extended care facility." -2 4. That the Tiller County Nursing Home, which is staffed by interns from A subsequent meeting involving the physician administrator of the Tiller County Nursing Home was arranged, to explore the alternatives of (1) establishing organized medical staffs in the two long-term care facilities, or (2) developing an alternative plan to satisfy certification requirements. After discussion, it was agreed that the most desirable approach might be joint involvement by the Medical Center, County Medical Society, Scottish House and Tiller County Nursing Home in developing criteria and establishing a common utilization review plan including the Medical Center's convalescent beds and those of the two long-term facilities. It was felt that this alternative would offer the following advantages: 1. 2. 3. 4. It could provide a means for identifying the level or intensity of nursing care each institution was best able to provide, thus assisting in appropriate placement of patients, expediting continuity of care, and avoiding unnecessary duplication of services. It could serve as a nucleus or foundation around which to develop additional functions required of the two long-term institutions under the conditions of participation. Involvement of the medical society might act to stimulate greater interest in and appropriate use of long-term facilities by physicians in the county. Such a group could, in time, with appropriate expansion in membership, Problems: 1. In a review of extended stay cases, it was pointed out that the average length of stay in Tiller County nursing homes approached three years, and that individual review of each case of extended duration in the two nursing home facilities might consume impractical amounts of time under the proposed joint arrangement. What might be done to relieve this situation? -3 2. Although joint involvement was approved in principle by the governing bodies of the Medical Society, Scottish House, Tiller County Nursing Home, and the Medical Center in utilization review, no decision was made as to the composition of the committee. What would be an appropriate committee: who should be on it? how large should it be? 3. What areas does the formally constituted Utilization Review plan have to cover in order to be acceptable to the Department of Health, Education, and Welfare? 4. 5. With the joint Utilization Review committee as a functioning nucleus, what are some of the other functions in which the committee can be of assistance? Given the situation as outlined above, what should be logical courses of action for the other four nursing homes in Tiller County? (Colonial Hills, Roadmere, The Fords, and Wilderness.) CASE STUDY CASE B DEVELOPMENT OF A UTILIZATION REVIEW PLAN AND OTHER FUNCTIONS REQUIRED OF A "PROVIDER OF SERVICE" Possible Solutions to Problems and Discussion: 1. 2. In a review of extended stay cases, it was pointed out that the average length of stay in Tiller County nursing homes approached three years, and that individual review of each case of extended duration in the two nursing homes might consume impractical amounts of time under the proposed joint arrangement. What can be done to relieve this situation? a. It was suggested that this function might be assumed by the fiscal intermediary, in this case the local Blue Cross-Blue Shield Plan which had contracted to act as "carrier" under the Medicare law. C. It was further agreed that the Medical Center's own utilization review committee would assume responsibility for review of extended stay cases in the Center's convalescent unit. The joint utilization review committee would thus not be involved in determination of fiscal liability on the part of the government and could focus primarily on surveillance and improvement of patient care. Although joint involvement in utilization review was approved in principle by the governing bodies of the Medical Society, Scottish House, Tiller County Nursing Home, and the Medical Center, no decision was made as to the composition of the committee. What would be an appropriate committee? Who should be on it? How large should it be? a. This particular committee was to be composed of three physicians from the utilization review committee of the Medical Center, three additional physicians nominated by the Medical Society, the physicianadministrator of Tiller County Nursing Home, and on a consulting basis for the utilization review function, the administrator of Scottish House and the directors of nursing service from all three facilities. The Records Librarian of the Medical Center was also involved on a consulting basis. 3. What areas does the formally constituted Utilization Review plan have to cover in writing in order to be acceptable to the Department of Health, Education, and Welfare? a. The organization and composition of the committee. -2 4. 5. d. e. f. g. h. The method to be used in selecting cases on a sample or other basis. The definition of what constitutes the period or periods of extended duration. The relationship of the utilization review plan to claims administration by a third party. Arrangements for committee reports and their dissemination. Responsibilities of the facility's administrative staff in support of utilization review. With the joint Utilization Review Committee as a functioning nucleus, what are some of the other functions in which the committee can be of assistance? a. b. c. By including in committee membership on a consulting basis a medical social worker, physical therapist, and other appropriate health disciplines, the committee or a subdivision of it might also act in a Policy Committee capacity for the two nursing home facilities. Assist in the developing of Transfer Agreements among the three Assist in the development of an on-going program for improving the skills of personnel in all three facilities in working with chronically ill or aging long-term patients. 1) 2) Plan in-service training programs for nursing home staff conducted by nurses, therapist, dietitian, and other professional personnel of the Medical Center. Enter into contractual arrangements between the nursing home and Given the situation as outlined above, what should be logical courses of action for the other four nursing homes in Tiller County? (Colonial Hills, Roadmere, The Fords, and Wilderness). a. Colonial Hills is the only one of the four that is in a position at present to become eligible for participation in the Medicare program. It would be logical for this newly-opened facility to try to become a member of the joint utilization review program. It remains to be seen whether this additional facility would be welcomed. The other three facilities are not large enough to qualify on their own, but participation in a community-wide program such as the one visualized above might enable them to qualify in time. It would seem to the interest of the community to have all facilities join in whatever efforts are being made to insure utilization of all health facilities in the county. |