Veteran CM keeps focus on cases he can impact

Set priorities, refine reports, he says

At the busy Massachusetts General Hospital emergency department, which sees between 200 and 250 patients a day, case manager Peter Moran, RNC, BSN, MS, CCM, says his focus is always on these questions: Why is the patient here? Why is the patient being admitted? What needs to be done, and is there a possibility it can be done in a [less acute] setting?

"If you can move them," he adds, "what are the barriers to getting them out? Some clearly can go home, some clearly need to be admitted, but the struggle is to identify cases where case management can have an impact."

One of the things that has the biggest payoff in terms of answering those questions in a timely and effective manner, Moran says, is to quickly identify patients who have the potential to be moved. One target, he notes, might be those who are on Medicare and who have had a three-day stay in the hospital within the past 30 days.

"Patients who meet those criteria and who are found not to have an acute medical condition can be moved directly from the ED to a skilled nursing facility [SNF]," Moran says. "The key is having the correct information."

Another trigger might be certain diagnoses, he points out, noting that a lot of chest pain cases, for example, can be put on observation status, depending on whether the patient has a history of heart problems — and a lot of payers want them in that designation. If the correct designation occurs up front in the ED, Moran says, claims can be processed and paid more quickly, with fewer denials.

One problem with finding the cases in which one can have a measurable impact, Moran continues, is that it's difficult to identify these patients without picking up every chart and scanning it — something that's difficult to do in a busy ED.

Mass General is in the process of implementing a faster way to identify these patients, he notes, through a report run off the information system it uses for utilization review, which also has a case management component.

He suggests that case managers develop a list of the types of patients they want to target and determine if reports can be generated based on certain diagnoses, repeat visits, or "whatever the [case management] program is aiming to impact."

"Try to use the systems you have," Moran says, "but sometimes the information you want is not found in a standard report. A lot of us have systems that are not state of the art, so you need to create special reports."

Although Mass General is still fine-tuning its new report, it has been helpful, he adds. "When I come in, it's not unusual for me to have 15 or 20 people waiting for admission. If I see someone had a Medicare admission and discharge within the past 30 days, I look at those charts first."

On the other hand, if someone comes in and is definitely going to be admitted, that case is not a priority, Moran says. "With certain payers, you can't move a patient [to another level of care] without pre-approval, and that will impact how I prioritize certain cases.

"For example, I know for a fact that with Massachusetts Medicaid, I need pre-approval to send someone to an SNF or rehab facility," he says, "so if a patient comes in over the weekend, and if he can't go home, that's a patient I cannot impact — he will be admitted. I can do an initial assessment, I can identify where the patient would like to go and I can have the patient screened, but I know I can't get approval until Monday."

Complicating the process, Moran notes, is the fact that most EDs are "getting overwhelmed with geriatric and mental health [cases]. The patients are getting older, and a lot of them are alone.

"We're also starting to see more people who are primary caretakers who need to be admitted to the hospital," he adds. "When they get hospitalized, what happens to the person they are caring for? If the 92-year-old [patient] has been taking care of a mentally impaired person, who is now 64, is there a way we can arrange for someone to take care of the dependent? Can we mobilize family members or community agencies?"

If not, Moran notes, such patients will frequently present to the ED and may become "social admissions" — patients who have no acute medical needs but who are not safe to discharge.

During the hours of 9 a.m. to 7 p.m., when case management services are available, there is time to see only so many patients, he says. "I'm being used for the person who is in the ED because he or she had a fall, is frail, elderly, and lives alone, and for the homeless and uninsured populations."

In addition, Moran says, he is consulted by physicians and families looking for assistance in caring for chronically ill people at home.

In looking at whether the person is fit to go home, he points out, he must consider what the person's baseline is: "How are they managing? What services are in place? So many are chronic — they're at home on a banana peel anyway — the question is, ‘Is [the current condition] different, or is this their baseline?'"

Meaningful measurements

One question that needs to be addressed, Moran says, is whether information systems are measuring the work that case managers are actually doing.

"We've had an ED case management program since 1995," he notes, "but it became apparent that the information we were collecting was not necessarily what we wanted to have, so we sat down as a group to talk about what we want.

"We had a report that was capturing the number of patients referred to SNFs and to rehab, and the cases where we had to arrange for assistance with medications and were involved with getting transportation, but the job has evolved over time.

"We can say that the nurse saw the patient and that he went to rehab," Moran adds, "but would that have happened anyway? What was the impact of the case manager?"

Moran says he receives calls from case managers across the country who want to discuss their experiences in ED case management. "Some say their programs failed, some say they were successful, but I always ask them the reason they are putting case management in the ED," he notes. "There are so many things we can spend time on. How are we going to evaluate the impact of having the case manager there, and does everyone understand why we're doing what we're doing?"

The key, he emphasizes, lies in recognizing the problems that a specific institution is trying to address. "Some have low capacity — they won't try to divert patients if they can get them admitted and be reimbursed for the care. Or the purpose of putting [a case manager] there may be getting those coming in for primary care hooked up with a clinic appointment.

"When people say they want to create an ED case management program, I say, ‘OK, but how [is the institution] going to measure the success or failure of your program?'"

He recently spoke to a case manager at a county hospital in south Texas, where there is a shortage of physician specialists, Moran says. The problem, he adds, was that people were told to come to the ED to get services, and then the expectation became that the case manager would arrange for specialty follow up.

"There were no more positions, just this added responsibility," he says. In such cases, Moran advises, case managers need to be able to document that — while this is not a typical case management function — it is a major problem in that location that they are trying to solve.

"It's an institutional priority," he adds. "It may not be what [case managers normally] do, but it is what they want the program to do, and it takes a great deal of time."

Moran says he told the caller — who was frustrated at not having the coverage to perform this task along with more usual case management work — to say she was willing to do the specialty follow up, but hospital leadership must realize she might not be able to do something else. He also suggested that she do a study showing how much time the specialty work entailed.

"I now advise people that whatever the program, they must know its purpose, the institutional goal, and how to measure success and failure," he says. "You can get pulled in 30 different directions, and they're all important, but you have to prioritize.

"You must be able to say, ‘I'd love to help you, but I need to do this.'"

[Editor's note: Peter Moran may be reached at pmoran3@partners.org.]