Case managers are the logical leaders in their hospital’s effort to follow clinical pathways, says Larry Burnett, RN, MS, managing director for Huron Healthcare, a healthcare consulting firm with headquarters in Chicago.
“Case managers are the ones who see the complete picture of the patient as they coordinate care. They partner with the physicians and nurses on the unit and are responsible for ensuring that patients get what they need to safely transition through the continuum,” he says.
Moving the patient through the system should be a team effort and not just the responsibility of the physician, Burnett adds.
“To succeed, clinical and organizational leaders must effectively synchronize the efforts of physicians, nurses, and ancillary departments to increase communication and focus attention on providing evidence-based, medically appropriate care at the right time and in the most appropriate setting,” he says.
Burnett recommends daily interdisciplinary care coordination conferences during which every patient in the hospital is discussed for one to two minutes. “Rather than focus solely on discharge logistics, such as transportation arrangements, the participants emphasize clinical progression by discussing medical milestones, where patients are on the pathways, and what interventions need to occur to help patients achieve the key milestones,” he says.
The meetings should be attended by the case manager, who leads the discussion, the nurse manager, the bedside nurse and, when possible, the attending physician. “We encourage physician participation and coordinating the conferences around the physicians’ schedules,” he says.
Ancillary care providers should participate as needed. For instance, call in a therapist for orthopedic patients or a pharmacist for a patient with sepsis, according to Burnett.
“One of the big challenges is getting people to use the pathways. A lot of work has gone into them. They include guidelines from physician organizations, but they often aren’t used,” says Karen Zander, RN, MS, CMAC, FAAN, president and co-owner of the Center for Case Management.
Use your case management software to track avoidable delays, variances, and the costs associated with overuse and bring the data to your physician leadership or administrators, suggests Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts.
Cesta recommends asking the medical leadership to intervene if physicians won’t follow the guidelines. “Hospitals can’t tolerate over-utilization anymore,” she adds.
Some hospitals are getting tough with physicians who don’t follow the guidelines and take away their admitting privileges, Burnett says.
Burnett recommends monitoring adherence to the pathways while the patients are still in the hospital. “Any variations that are not adequately documented as appropriate should be concurrently managed through an escalation process that involves the leadership of the appropriate discipline, such as the physician advisor, the section chief, or the chief medical officer,” he says. In addition, retrospectively collect data on adherence and send it monthly to the medical executive committee that is responsible for ensuring appropriate clinical care, he advises.
“Physicians have a lot of different beliefs and practices based on their training and experience. Clinicians must work together to develop evidence-based care pathways and hold one another accountable for adhering to them,” he says.