Discharge Planning Advisor

It takes all CM functions to provide necessary care

Care coordination 'least recognized'

Many top hospital decision makers still fail to recognize that case management is a core function of patient care, not an optional service that needs to prove return on investment, says Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of the Center for Case Management in South Natick, MA.

Even those who do acknowledge that case management is part of the basic structure of a hospital may not see all of its components as crucial, says Zander.

Hospitals have accepted that utilization review (UR) has "tightened up" so that it is no longer just about having good contracts with payers, but must be practiced on a daily basis and must be done mostly by nurses, she says. "Case managers have to implement the contracts. UR has gone from a blanket, 'We'll get paid, just send this off' to having to explain why we deserve to be paid for this day for this patient."

"If we say, 'This is what we need for UR,' [administrators] wouldn't balk at that, but the functions keep evolving and growing," Zander adds. "If we start with one staff [member], they say, 'OK, we understand,' but then we keep throwing more responsibilities on that staff [member] and the complexity of cases [keeps increasing]."

Having an electronic medical record makes the job of UR easier, she notes. "The problem is that no one has a complete electronic record, so you have to look at the computer for some information, the paper chart for the rest, and then you have to track down the physicians to see who's covering for whom."

The next most acknowledged case management function is discharge planning, Zander continues. "People know that patients can't live in the hospital for the rest of their lives, so they have an intuitive understanding that discharge planning has to happen.

"They also know that length of stay and getting paid are connected, so there is even more recognition of the importance of discharge planning, and there is a target attached," she says.

"In fact, there are several targets attached," Zander adds. "The more the quality targets rise, the harder the job. It's not just finding a place for the patient to stay, but, [asking], 'Have we done the right thing to prevent readmissions, are we doing the right work in the hospital, and are we sending the person to the right level of care?'"

There are long-term acute care hospitals, but they don't usually take Medicare, she notes, "so you might have a patient who can use that, but has the wrong payer."

The Center for Case Management estimates that 45% of a hospital's medical-surgical patients should be going somewhere besides home at discharge "and we think that [percentage] is low," Zander says. "The recovery phase of [hospital] care got amputated with DRGs.

"What we mean by 'somewhere,'" she adds, "is somewhere where there is nursing oversight and actual nursing care, such as long-term acute care, hospice care, home care. Even one home visit we count."

In actuality, Zander says, most hospitals are at 20% and, with readmission rates on the increase, "will have to ramp up."

The access function is the third, less acknowledged, component, she says, "although it has always been a foundation of case management. It is about getting patients connected with health care services, especially the front end of the care.

"That includes getting patients into and through the emergency department; getting them a bed if needed; acquisition of a primary care physician, appointments, transportation, and other resources," Zander adds. "Liaison staff to community agencies are also working in the access function."

The fourth function of case management, care coordination — "the middle of the care" — is the least recognized, she says. "It's about team leadership, treatment planning, and quality, not just what the physicians are doing, but what all the other services are doing in regard to basic care, like pain management and mobility and patient education.

"Are they getting confused? Are they dehydrated? What is their pulse oxygen? Are we mobilizing them correctly? Do they understand how to take care of themselves?"

If caregivers aren't paying attention to those questions, Zander points out, "four days can turn into 40 days. It slips into that very fast if you don't manage those things.

"We have a little poem at the [Center for Case Management]," she notes. "UR is accountability for the pay, care coordination is accountability for the day, discharge planning is accountability for the stay, social work is accountability for the way, and access is accountability for today."

If a hospital's executive team doesn't understand all the necessary functions, and how case management will serve those, and if there are no real targets in place to show where a hospital wants to get, Zander says, whatever staffing was allocated at a case management department's inception is likely to remain.

"If social workers did discharge planning and nurses did utilization review [originally], then you are stuck with that unless the hospital sees the access and care coordination issues," she adds. "Unless [administration] sees the scope of what you have to achieve, you get into a fall-back position instead of an aggressive one."

(Editor's note: Look for a case management staffing model developed by Karen Zander for the Center for Case Management in the next Discharge Planning Advisor.)