The ED is a frantic, high pressure point of entry at hospitals. Yet, key decisions are made that impact the financial and quality outcomes of the patient visit. Currently, ED medical teams treat and document the major elements of patient care. A patient presents to the ED with trauma from an auto accident: concussion, rib fracture, etc. But, what about other risk factors that put the patient at risk for developing problems during the hospital stay? Do renal chemistries suggest a pre-existing renal condition or evidence of subclinical renal injury that could develop into a clinically significant problem later during the hospital stay?

At Wishard Health Services in Indianapolis, Indiana, it was recognized that within the frantic pace of the ED was a missed opportunity to not only ensure correct patient status, but adhere to core measures, evaluate present on admission (POA), be RAC-ready and avoid hospital acquired conditions (HACs). Clinical Documentation Specialists, who currently are responsible for documentation deficiencies, are being called on at Wishard to provide a deeper level of assessment of the medical record in the ED setting and work with the clinical team to identify parameters in the chart that put the patient at risk. Presently there are some real, specific ways hospitals can begin to shore up some weaknesses in the patient care process when it comes to documentation.

Wishard's clinical and business integration team identified the lack of a defined process leading to deficiencies in the ED. This brought about the development of a clinical integration process within the ED that helps them achieve correct admission status, adherence to core measures and CMS programs that impact reimbursement, such as HACs, POA and Value Based Purchasing. Challeges were to create a new position and then integrate that position with ED physicians and case managers and have all more involved in the quality component and more fully aware of potential risks and problems that could develop.

The key outcomes include:
The creation of a new Clinical Integration Specialist role in the ED a nurse who is charged with determining appropriate admission status, documentation improvement opportunities, POA documentation, and specified core measures. This new role provides an additional level of assessment of the medical record and patient and works with the physician team, quality staff and case managers to ensure all the key parameters are identified which will lead to better outcomes for the patient.

A collaborative work model between the new Clinical Integration Specialist role and case managers which helps anticipates problems on the floor these presumptive diagnoses can spur case management to become engaged in avoiding future, avoidable problems and calibrate intensity of services needed.

Admitting doctors get better picture on the details behind why and under what conditions a patient was admitted, leading to better outcomes and core measure adherence.

Case mix indices match true severity and reimbursement less impacted by mis-steps on RAC and POA/HAC requirements

Physicians are ranked more accurately when it comes to the quality reporting such as HealthGrades, etc.