Can medical care be effective
and efficient, too?
A nurse's year as a case manager indicates the answer is 'yes'
By Jim Barrett
Whoever heard of medical costs going down?
At University Hospital in San Antonio, one of the Health Science Center's teaching hospitals, a yearlong experiment in managing orthopaedic surgery has halved the length of patient stays and reduced the cost of surgery as much as 36 percent.
"This approach has been thought about. It's been written about, but very seldom does it actually get implemented," said Lisa A. Wammack, RN, MSN, who leads the program.
Wammack is an "outcomes manager," or case management nurse, a field with explosive growth because of efforts to streamline health-care delivery. Hundreds of hospital nurses like her in the United States are learning to contain costs without sacrificing good medical care.
Case managers usually are experienced clinical nurses with advanced degrees. They know medical care and they know about the bottom line. Wammack is a Health Science Center graduate. She pursued case management in obtaining her master's from the School of Nursing.
As master troubleshooters, case managers monitor all aspects of a patient's care and become the patient's advocate and primary contact. They have administrative powers once reserved for physicians. Case managers watch to avert problems in the hospital -- redundant tests, missed communication, scheduling conflicts that cause delays.
Wammack works with the patient long before he or she is hospitalized, and often for weeks after the patient's discharge. No patient is admitted to the hospital until he or she is ready for surgery and the step-by-step schedule, or "critical pathway," leading to discharge is certain.
Jay D. Mabrey, MD, director of adult reconstruction surgery at University Hospital and assistant professor of orthopaedics, hired Wammack in January 1995. Dr. Mabrey was certain the system would work.
"Much of the time that was wasted before we started the case management program was a result of inefficient use of the patient's time in the hospital," said Dr. Mabrey, who performs more than 100 hip- and knee-replacement operations a year.
Case management has worked well.
Last year, Dr. Mabrey's hip-replacement patients had an average hospital stay of five days, down from nine days in 1994. The cost of surgery also dropped, down 36 percent from $17,937 the year before. There was similar success with knee-replacement patients. Their average length of stay dropped from 10 days to five days, and the cost dropped 20 percent, to $10,236.
The results have been convincing. Case managers soon will be used for University Hospital patients needing trauma care, gall bladder surgery, leg vessel bypasses and certain types of cardiovascular surgery.
Wammack and many other case managers use sophisticated computer data bases to identify and predict potential complications before a patient is scheduled for surgery. She also searches for sources of payment that otherwise might be overlooked. Coupled with the cost savings, her work has made both types of surgery profitable for the hospital.
But some of her accomplishments come from old-fashioned instinct and savvy gained over the years in the hectic hospital setting.
Last Thanksgiving, for example, Wammack averted a delay that could have prolonged a knee patient's hospital stay and cost an estimated $4,000. Only days before the patient's surgery, Wammack found out the hospital planned to close its physical therapy department for the holiday.
On the phone, she told a hospital manager: "If this patient doesn't get physical therapy on Thursday, he can't go home on Friday. We're blown out of the water. He'll have to spend at least another day in the hospital, and that puts it off until Saturday or maybe even until Monday."
She was prepared to postpone the operation. Then the phone rang. A physical therapist would be on duty, keeping the patient on his "five days-and-out" hospitalization plan. He was discharged Friday, right on schedule.
All hospitals are searching for ways to be more efficient, but the need is pressing for University Hospital and the nation's 300 non-federal academic hospitals. Patient costs at these hospitals traditionally are about 30 percent higher than at private hospitals, and health reform plans frequently have proposed reducing the Medicare subsidies to the teaching hospitals. Academic hospitals pay salaries for faculty and trainees, perform expensive specialty medical services and treat more poor patients than private hospitals.
Do patients suffer because of brief stays in the hospital? Wammack and Dr. Mabrey say no.
"Our patients work harder at their physical therapy. They are mobilized earlier so there is less chance of complications such as pulmonary embolism, deep-vein thrombosis and pneumonia. The patients know they are going to go home in five days and they want to be ready to go," she said.
Despite all planning, some patients must stay longer. Sometimes things work better than planned, too.
Take for example Lowell Shoemaker, a small-business owner from San Antonio. He came on a Monday morning in January and left with a new right knee on the following Thursday, just three days after surgery and a day sooner than most.
"Before I ever came in, Lisa and the doctor told me how long I would be in the hospital, and approximately how long the recuperation period would be. It takes about six weeks. I knew what to expect. They told me it wasn't going to be easy, and that the therapy at first would be rather strenuous, and so it was, but it was worth every tear," Shoemaker said.
Nurses are uniquely qualified to lead a medical team through a patient's hospitalization, said Leslie R. Goddard, PhD, assistant professor of acute nursing care.
"Nurses have the ability to go across the health care disciplines very well, to communicate for the patient, and to see the big picture. They can talk to the physicians, the social worker, the physical therapist, the occupational therapist, and collaborate to get things done," Dr. Goddard said.
Critics say academic hospitals have devoted more attention to education than costs, and some health-profession educators agree. "We have all gotten a wake-up call about efficiency," said James D. Heckman, MD, professor and chairman of orthopaedics at the Health Science Center. He directs the orthopaedics residency training program at University Hospital.
Case management systems will be widely used in coming years to treat many illnesses, Dr. Heckman said. "This isn't merely a dollars-and-cents issue. With case management, patients are much more satisfied with their care," he said.
Recent changes in the nation's health-care system have been chiefly the result of business pressures and not legislation. Many medical professionals view case management as a way to streamline the system, preserve their prerogatives in treatment, and avert cost-cutting mandates.
"Doctors and nurses don't want insurance managers telling us how to do our business," he said. "We want to keep control of the health-care system, and the patient's welfare."
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