CM redesign breaks down barriers
Initiative sets role expectations
To function more efficiently in today’s healthcare environment, the case management department at OSF Saint Francis Medical Center in Peoria, IL, underwent a comprehensive redesign that sets out clear role expectations, developed outcome and accountability measures, and promotes a proactive approach to patient transitions.
Executive Summary
OSF Saint Francis Medical Center in Peoria, IL, redesigned its case management department to improve efficiency and clearly define the role of each clinician.
- The redesign combined the roles of discharge planner and the patient care facilitator to create the role of care transition coordinator, created a new role of complex discharge planner, and added clerical support to the department.
- The restructure divided the hospital into five zones, and one care transition coordinator from each zone covers the weekends on a rotating basis. A complex discharge planner works on Saturday.
- The format the care management team uses to make notes in the records was standardized so it's consistent on all units.
"When we began the restructuring project in 2011, we had significant resources in place, but we were not getting the outcomes we wanted. With the Centers for Medicare & Medicaid Services penalizing hospitals for excess readmissions and the beginning of value-based purchasing, we knew we had to figure out how to improve or restructure the department," says Jane Counterman, RN, manager, care management.
At the time, the case management department had patient care facilitators, discharge planners, social workers, and designated utilization review nurses but provided slim coverage on weekends, Counterman says.
The new structure was designed by a multidisciplinary team that analyzed the case department and determined that a big part of the problem was the lack of expectation for each role, says Leslie Foti, RN, BSN, supervisor for transitions and outcomes.
"There was a lot of crossover among the tasks that the patient care facilitators and the discharge planners were doing. The work of the discharge planners was largely reactive and driven by consultations," she says.
The members of the redesign team realized that they needed to develop clear role expectations, accountability measures, and consistency in what was being addressed on each unit.
In the new structure, the many facets of the roles of the discharge planner and the patient care facilitator were combined to create the role of care transition coordinator.
The redesign team created the new role of complex discharge planner, an RN who handles complicated discharges. They added a new job, case management assistant, who provides clerical support for the care transition coordinators, the complex discharge planners, utilization review nurses, and social workers. The social worker and utilization review nurse role did not change.
The care transition coordinators are responsible for care coordination, length-of-stay management, simple discharge planning, patient care conferences, and for calling patients after discharge. They also assess and coordinate care for patients receiving observation services. "When patients are in observation status, we talk with the physician daily to determine if they need to be admitted or, if not, what they need to move on," Foti says.
Each care transition coordinator is also responsible for performing a chart review on two readmissions each week to determine why they occurred. "This arrangement has built-in accountability. It helps the coordinators identify areas where the discharge plan failed and make changes accordingly," Foti says.
In the original structure, there was one manager over utilization review and patient care facilitation and a separate manager for social work and discharge planning.
Under the new structure, there is one department manager, along with five frontline supervisors for care transitions, one for social work, and one for utilization review. The frontline supervisors work two days on the floor and three days as a supervisor.
For example, Foti is a care transition coordinator for two days a week and a supervisor for the rest of the care transition coordinators in her zone of the hospital for the rest of the week. "This gives the supervisors the big picture. They can see firsthand what is happening, and it helps them break down bigger barriers," she says.
Prior to the restructure, two discharge planners worked on weekends and covered all 600 beds. After the restructure, the team divided the hospital into five zones, and one care transition coordinator from each zone covers the weekends on a rotating basis. A complex discharge planner works on Saturday. The supervisor covers the shifts when the care transition coordinator is assigned to weekend duty.
"Because I am also working on the floor, I can provide real-time feedback to the staff. In essence, I am auditing people every time I cover their shifts," she says.
The goal under the new structure is for case managers to see every patient and complete an initial assessment on Day 1 and to discuss all observation patients with providers each day.
The assessment identifies early on what kind of support the patient is going to need after discharge and the payer source. "We start asking the physician ahead of time if the patient will need home health or outpatient treatment so we can have everything in place when the patient is ready for discharge," she says.
The team standardized the format the care management team uses to make notes in the record so it’s consistent on all units. "The notes in the electronic medical record cover the same topics in the same order. This way the case management staff knows where to look in everybody’s notes to find the information they need," she says.
For instance, the first items in the notes identify the primary problem, the anticipated length of stay, goals, and barriers to discharge. There is a place for information about the home situation, who will provide support after discharge, and the patient’s prior level of functionality, she says.
"At first, the staff found the format constrictive, but they have come to appreciate the consistency. Now when a patient is moved from the step down unit to the medical/surgical unit, the care coordinators who are receiving the patients know where to look in the notes to find the information they need," she says.
The redesign focused on breaking down barriers, Counterman says. For instance, in the previous structure, each of the two managers were responsible for about 50 employees each. Now with fewer employees to manage, the managers have the flexibility to work on any trends and barriers they identify and can escalate a response a lot faster, she says.
For instance, if there are new regulations from payers, the frontline supervisor can huddle with the team, inform them of the changes, and answer questions. "In healthcare today, regulations and rules change quickly. Email is a great way to communicate, but it doesn’t give employees the opportunity to learn from other employees’ questions," she says.
Foti calls case managers "the special ops of healthcare. We catch the first wave of new regulations and other challenges. Not a single day goes by without somebody asking us to do something challenging and we make it happen," she says.
