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RNs, LCSWs cross-trained to work as case managers
One person is go-to for patient, family, insurer
When Brookhaven Memorial Hospital Medical Center redesigned its case management function, merging the social work, utilization review, and clinical guidelines departments, the hospital cross-trained staff in all three departments to handle case management functions.
"We wanted to improve service to patients by having just one person — a case manager — go to the bedside and coordinate their care and communicate with the rest of the health care team and the managed care companies," says Ellen Salvo, LCSW, director of case management and utilization for the community hospital, located in the town of Patchogue in Long Island, NY.
The model is effective because there is one person for the doctor, the family, and the patient to contact for information; no one has to track down several people to get a picture of the patient, Salvo says.
"When a managed care provider needs to know about a patient, there is one person to talk to who knows the treatment plan, how the patient is progressing, whether he still meets criteria, and what the plan is for discharge," she says.
Before the reorganization, social workers had handled discharge planning and worked with patients with high-risk social issues. The utilization nurse handled utilization review. In addition, the quality management department was responsible for quality issues.
When the departments were combined, staff working in all three positions were cross-trained to handle all of the tasks of both disciplines.
"There were three different people looking at the chart and reviewing the information. This was not as efficient as it could be," Salvo says.
When the departments were combined, staff who had been working in all three positions were cross-trained and began working in teams of two. The skill sets that each person brought to the team made it possible for one person to handle all the functions required, Salvo adds.
In order to make it work, the hospital created case management positions, which were filled by the social workers and the nurses from the utilization management department and the quality management department.
"They each are called 'case manager' and they work together as a unique and powerful team. They can bring all their skills to bear in resolving any issue and performing any function that it once took more people to accomplish," Salvo says.
The case managers have specific geographic assignments in the hospital and are responsible for coordinating the care of patients who come into those beds. Each case manager is assigned to about 15 beds and is responsible for the main functions of utilization review and discharge planning for those patients.
"The actual caseload can vary due to patients being discharged and new patients being admitted," Salvo says.
Although team members have total responsibility for their own caseload of patients, they collaborate closely with their team and other disciplines when appropriate to coordinate care for the patients.
"If it is a clinically complex issue, the case manager with a social worker background draws upon the other team member as a consultant and vice versa. If a case manager with a nursing background has a case with a lot of social issues, their teammate with a social worker background would be the consultant," she says.
The multidisciplinary model extends to the management team, which includes a supervisor who is a social worker and a manager who is a nurse with a strong utilization background. Salvo, the director, is a social worker.
"We are a team and we rely on each other's skills and education. Everybody has learned to appreciate the work of their counterparts. If people are accustomed to doing one particular job, they tend to be focused on their responsibility and work independently of other people. In this model, people with different sets of skills and education work together and learn from each other," she says.
The two disciplines rely on each other for help in challenging situations and work together as a cohesive team, Salvo says.
"Many times, people are not able to determine who is the nurse and who is the social worker on a team. There is a lot of cross-training and learning," she says.
The case managers are part of the multidisciplinary team and participate in daily patient rounds, along with the medical director for case management, the nurse manager, and the nurses on the unit to review each patient.
The case managers are supported by the department's placement office, which handles placement for short-term and long-term post-acute services and by case assistants who work on each floor, to assist in carrying out the discharge plan developed by the case manager.
The case managers meet with the patients and family to discuss discharge planning and communicate the plan with the health care team and the physicians.
They notify the placement office to locate beds for patients who need short-term or long-term post-acute care.
The placement coordinator identifies available beds in facilities and seeks authorization for payment from the patient's insurance. If it's a short-term placement, they pass the information on to the care managers who discuss the choices with the family.
If it's a long-term placement, the patient and family meet with the placement coordinator to talk about the placement process.
One case assistant is assigned to each floor and works with four case managers. Part of their function is to handle nonclinical duties such as faxing, copying, and other details that help get the work done.
The case managers and case assistants have laptops and zone phones, which are tied to the hospital switchboard.
"They can do a lot of their work right in the patient room on the laptop. It makes it much more efficient," Salvo says.
A team of case managers and a case assistant works from 8 a.m. to 4 p.m. on Saturdays and Sundays.
The hospital typically has a case assistant and two or three case managers covering the emergency department and the entire hospital on weekends. The number of staff depends on anticipated volume.
The weekend staff are a combination of full-time case managers and per-diem case managers. The full-time staff rotate on the weekends and take compensatory time off during the week.
"We try to limit the full-time staff on weekends because it leaves us short during the week," Salvo says.
As part of its initiative to improve patient throughput, Brookhaven Memorial Hospital Medical Center has hired facilitators who work with the high-volume physicians on issues when they aren't in the building.
"They can write prescription orders and complete the discharge summaries so it doesn't delay the discharge," Salvo says.
In addition, the case management department is working with nursing homes and other agencies that provide post-acute care to facilitate discharges over the weekend.
"We've educated them that we are a seven-day-a-week facility and that there will be discharges on Saturday and Sundays. They are working with us to help ensure that our patients get the post-acute services they need seven days a week," Salvo says.
(For more information, contact Ellen Salvo, LCSW, Director, Case Management and Utilization, Brookhaven Memorial Hospital Medical Center; e-mail: email@example.com.)