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Increasingly, hospital-based case managers have had to take on a conglomeration of duties, serving as utilization manager, discharge planner, and clinical case manager, among other things. When the caseload is reasonable, the case manager’s skill set well rounded, and the department empowered, the integration of functions is highly successful, says Maria Hill, RN, MS, CMAC, senior consultant with the Center for Case Management in South Natick, MA. If those pieces aren’t in place, Hill cautions, the results can be less than desirable.
"There is good and bad [to combining the three roles]," she explains. "The good part is that you are streamlining systems so that when the case manager is looking at the medical record and patient/family, that individual can ask, What is the primary diagnosis? What are the comorbidities that may complicate the case? Do the treatments, tests, and medications being administered meet the criteria for a hospital stay? What resources will be used during the hospitalization?’"
Understanding the severity of illness, the intensity of service, and the complexity of the plan of care helps the case manager craft the clinical outcomes to be achieved and the discharge plan to be put in place, Hill says. The overriding challenge is to balance clinical and financial considerations, she points out. This can be accomplished if the case manager has a manageable caseload, is not required to cover too many inpatient units, and has administrative support, she adds.
Difficulty arises when case managers are asked to see too many patients and to cover too much geography, she notes, as when one case manager is given responsibility for the emergency department (ED), the intensive care unit, and the general care units. The challenge becomes even more overwhelming, when case managers also are expected to address such issues as length of stay, denied days, and costs of care without data and administrative support, Hill notes.
The proper ratio is one case manager to between 20 and 25 patients, she says, as long as no extraneous duties are added to the workload. If the case manager also is charged with doing infectious disease reports or collecting quality measurement data, that person won’t have sufficient time to perform well the three central functions, Hill points out.
Besides adequate time to do the job well, she suggests, the case manager who successfully does utilization review (UR), discharge planning, and clinical resource management must have a well-developed skill set that includes the following:
• Knowing the utilization review criteria that the hospital uses internally, as well as those used by the higher-volume payers. "The goal is to ensure the right level of care at the right place at the right time within the typical clinical trajectory for the diagnosis," Hill says. "By having a detailed knowledge of the UR criteria, the case manager can negotiate — through conversation with the payers — the appropriate place for the patient." Without this knowledge, she adds, the case manager won’t have the ability to properly articulate the reasons the patient whose condition is borderline when compared to the standard criteria should be in the acute care setting.
• Ensuring, as part of the clinical case management function, that daily outcomes are achieved and the patient is making progress in line with the care plan for the hospital stay. It is essential, Hill says, that the case manager establish procedures to manage care on a daily basis and against a standardized plan of care for the stay. "A targeted length of stay by diagnosis is essential," she adds.
The case manager also is charged with reviewing the care of both the individual patient and the aggregate population — all the hospital’s stroke patients, for example — against this plan of care for the stay, Hill says. With stroke patients, for example, the case manager should be looking at a four- or five-day expected length of stay, she notes, and should make sure that within an hour of presentation to the ED, the patient who meets criteria is given an antithrombic agent.
Within 12 to 24 hours, the case manager should ensure that:
— the patient is evaluated by a speech pathologist;
— a plan for communication and nutrition is established;
— the patient’s blood pressure parameters are set and blood pressure is managed within this range;
— the patient is evaluated by a physical therapist and an occupational therapist, and the resulting plan is written in the chart and acted on;
— immediate communication is established with the physician to review complications and exceptions to the stroke clinical plan of care for the stay.
• Understanding all aspects of discharge planning.
What’s key here, Hill suggests, is crafting "Plan A" and "Plan B" for the high-risk patient so that if Plan A fails, Plan B may succeed. It’s also crucial that the case manager know enough about the patient to measure the effectiveness of Plan A, and know the proper time to put Plan B into place.
Plan A for a stroke patient, for example, might be to send the patient home after discharge from the hospital. Part of the skill set required here, Hill says, involves working with the therapy staff to know what the predicted functionality of the patient will be at the end of the four- or five-day acute care stay. "That should be judged within the first 24 hours of admittance to an inpatient setting," she notes.
Another crucial component is evaluating family members’ ability to assist the patient in the home, and also evaluating their willingness to change their schedules in order to do so, Hill points out. "Once you know they’re able, [determine if they’re] willing to provide the assistance and surveillance necessary for the patient to function in the home."
In approximately 25% of cases, family members either get home and are overwhelmed at the prospect of caring for their loved one — in which case the person is readmitted — or they realize at the last minute that they can’t do it, she says. That’s why Plan B, the backup plan, must be highly viable, Hill explains. "The on-top-of-it case manager will have the ability to place a person in a skilled nursing facility or a rehab setting within 24 hours," she says. Knowledge of community resources is important, she adds, including good programs available for "special interest" patients, such as those with significant brain injuries, significant functional motor loss, or dependence on a ventilator.
Ideally, the case manager will have taken steps to avoid this last-minute regrouping, Hill explains. A "big red flag" to look out for, she adds, is family members who insist they can take the stroke patient home but haven’t spent any time in the hospital. Something Hill recommends, but which she says isn’t done enough, is for the case manager to have family members come to the hospital and then observe them taking care of the patient.
"[The case manager should] instruct them on how to care for the patient — helping mobilize, feed, give medication — and then observe them as they do these tasks," she notes. "I have had case managers do it, and [the family members] get a better picture of what the workload is, what their knowledge base needs to be, and whether they can actually manage their family member at home."
Another red flag, Hill adds, is discord within the family. "One person really wants to take mom home but can’t provide all the care, but another sibling is not interested in assisting." In those cases, she suggests, the case manager should try to arrange a family meeting and present the different views he or she is hearing from the members. "The key in these situations is to have an excellent relationship with a clinical social worker who can help a family adjust to the new diagnosis and change in the person’s functional ability," Hill says. "This helps the family know realistically what they can and can’t provide." She suggests that all stroke patients be assessed by a social worker within 24 hours of admittance to the hospital.
It’s important to have the family look at placement options, even when they’re thinking of taking the patient home after discharge, Hill says. "If you think Plan A might fail, encourage the family to visit facilities within their community. Let them know that you’re looking to the future, when they may need to put their family member in this setting for a short time."
In situations that are less than ideal, where the case manager is responsible for more than a reasonable number of patients, he or she will have to prioritize, she points out. "You have to perform utilization review on all patients every day or every other day, but you may do a good job with care planning and discharge planning only on the higher-risk patients," Hill says. "You would have to delegate to the unit manager or bedside clinicians the cases for which they would create a care plan and a discharge plan," she explains.
Role negotiations, she adds, should be at the administrative level, with oversight provided by a steering committee that helps establish policies and procedures. That committee, Hill suggests, would include such participants as the director of case management, the vice president of patient care services, and the vice president of medical management.