Success Stories:

Tift Regional Medical Center


Tift Regional Medical Center is part of a nonprofit health system that serves 12 counties in South Central Georgia. The 191-bed medical center, a regional referral hospital that serves as the system’s main campus, has been ranked as one of the top 10 medium-sized hospitals in the state.


The release by CMS of the inpatient Prospective Payment System Final Rule for 2014 — known informally as the “two-midnight rule” — left little time to operationalize the new determinants for meeting the inpatient criteria. The rule was released in late August of that year, and a number of changes mandated by the rule — involving physician order and length-of-stay attestation requirements — needed to be in place by a deadline of October 1.

TRMC’ leadership realized they needed help understanding the implications of the two-midnight rule for a system of their size. They would also need advice on ways to improve documentation to meet the rule’s requirements, along with training for physicians, patient care management staff, and other clinical staff members.


When the two-midnight rule was published, Xtend was already working with TRMC to implement a medical record review process for short-stay patients to ensure appropriate documentation and billing. After reviewing the new rule, Xtend and the TRMC team concluded that compliance would require changes in several of the hospital’s clinical processes. In revising the processes for documentation into electronic medical records, the team included physicians, case managers, and utilization review staff in the same explanatory process of the rule and in the plan to meet the changed requirements for inpatients.

Xtend compliance experts consulted with TRMC’s patient financial services staff to help them understand the rule’s instructions for conserving the time a patient had already received service in an outpatient area (e.g., emergency or diagnostic services.)

Xtend also coordinated training for patient care manager, who, under the new rule, would have to switch from long-established clinical assessment tools to an approach that depended on the physician’s evaluation and plan for the patient that indicated the need for care beyond the two-midnights threshold. A web-ex session with the patient care management team helped educate them about documentation requirements for an inpatient admission under the new rule and showed them various examples of regulatory-compliant accounting of the time that patients received outpatient care before physicians issue orders for inpatient admission.


Since all users were able to offer input into the revision of the EMR, it has served well to meet the needs for more specific documentation.

By revising system-posted account service notes and understanding the time stamping of registration in various service areas, Xtend helped TRMC case managers accurately estimate the length of time Medicare patients had been receiving outpatient services prior to the physician’s inpatient order.

Enabling emergency department physicians to discuss prior patient care with a clinical nurse manager meant that they could calculate the remaining length of stay the patient would need in order to meet the two-midnight inpatient criteria.

TRMC’s case management staff say Xtend has helped them identify areas of strength and others that need improvement, while impressing on them the importance of communicating patient information between staff and physicians — the key to success under the two-midnight rule.