Last month, we began our discussion of the top 10 mistakes you may be making in your case management department. After 30 years of experience in testing and retesting hospital case management models, it is safe to say that we have identified some basic elements that make for a contemporary and state-of-the-art case management department. In this month’s Case Management Insider, we will continue our discussion of the top 10 mistakes by reviewing mistake numbers 3-5.

Last month, we talked about the first two mistakes made by case management departments:

  1. Role confusion or, “Who is doing what?”
  2. Inadequate staffing ratios

Case Management Department Mistake Number Three: “Not Using the Best Practice Case Management Model Design”

Each of these mistakes feed directly into our third mistake, which has to do with the model design of the department. The model used for your department is critically important and relates directly to the roles and functions of the case managers and social workers as well as the staff-to-patient ratios for each discipline. So mistake number three is to not use one of the best practice model designs that have been tested and found to work well.

What is a model of care? A model is a description used to help visualize something that cannot be directly observed. Because care delivery models such as case management models cannot be seen, we use descriptors to provide a picture of the model in terms of its structure and processes. The field currently supports two contemporary models. Each is designed to address the challenges hospitals are facing today in terms of value-based purchasing, penalties for readmissions and high mortality rates, the efficiency measure, and other issues associated with the Affordable Care Act such as integration across the continuum of care.

The Integrated Case Management Model

In the integrated model, all roles are performed by a single RN case manager. This model integrates previously disconnected roles and functions. Included in the integrated model are all the roles we discussed in Part 1. For the registered nurse case manager, these include patient flow, utilization management, resource management, transitional and discharge planning (with a clinical focus), and avoidable delay tracking. For the social worker, they include psychosocial counseling and interventions, and discharge planning with a psychosocial focus.

The nurse case manager integrates the roles of patient flow, utilization management, and discharge planning into one role that applies to all patients assigned to her. The nurse case manager is responsible for referring any psychosocially complex patients to the social worker as they are identified.

The integrated model requires that all patients are seen by a nurse case manager. For some patients that are considered “high risk,” they may also be followed by a social worker.

Collaborative Case Management Model

In this model, a third team member is added. The third member is called the Utilization/DRG Manager, or “business associate,” and is responsible for the “business” aspects of case management such as conducting clinical reviews for the purpose of transferring information to a third-party payer. They are also responsible for clinical documentation improvement. As such, the staffing ratios are different in the collaborative model. The case manager is responsible for assessing, planning, and coordinating care and outcomes management.

Staffing Ratios in Collaborative Model

  • Case Manager: 15 – 23
  • Business Associate: 20 – 40
  • Social Worker: 1:17 active cases

These staffing ratios can be directly compared to the ratios we looked at last month that were for the integrated model. As you can see, the ratios for models in which utilization management is a separate function are different. The RN case manager can carry a larger caseload, but with the addition of the business associate, the cost can be higher overall as a third member is added to the team. The role of the social worker is the same in both models.

Each model brings pros and cons. The key differences between the two models are the integration of utilization management into the role of the case manager versus the separation of the role through the addition of a third team member.

How are These Models Alike?

Both the integrated and collaborative models build on the interrelationships of the nursing and social work disciplines to achieve the expected case management outcomes. They both require strong social work support and will not work if they are inadequately staffed. Caseloads and workloads must be balanced.

Case Management Department Mistake Number Four: “Lack of Clerical Support”

When implementing a case management model, there are some tools and support structures that should be in place to provide a foundation for the professional staff, the nurse case managers, and social workers. Mistake number four is not having clerical support staff to free up the case managers and social workers from performing functions that non-licensed personnel could/should perform.

Clerical support staff is an integral part of the case management department. They are a component that is often lacking and considered unaffordable or “not in the budget.” In reality, the lack of clerical support staff produces a lot of “time-wasters” for the case managers and social workers. They can actually optimize the staff ratios we have previously discussed by allowing the professional staff to engage in functions that only they can perform. By investing in clerical level staff, the entire department becomes more efficient and therefore more effective.

Titles and Roles

There are a variety of titles that can be given to your support staff. Some examples include extenders, case management assistants, clerks, expeditors, etc. These positions are gaining popularity as the role of the case manager has become more complex every year. Similar positions in nursing would be the nursing assistant who assists the staff nurse so she can work “to the top of her license.” So many case managers and social workers spend half their day faxing, ordering transportation and durable medical equipment, or on the phone trying to reach a facility or vendor. These tasks can be assigned to an extender. You can break out the work by categories and assign the tasks as per your own department’s needs and comfort level.

Extenders are utilized the most optimally if they are assigned to specific case managers and social workers. In this way a relationship can be formed between them. There should typically be one extender for every seven to eight professional staff. The extender should be assigned to the same professional staff every day.

Extender Roles in Discharge Planning

Below are some of the items that can be assigned to the extender to support the role of discharge planning:

  • Make packets for transfer to skilled nursing facilities (SNF), nursing homes (NH), rehabilitation facilities, or long-term care hospitals (LTAC),
  • arrange ambulance transport,
  • arrange taxi or care service transport,
  • take prescriptions to outpatient pharmacy and fill them for patients being discharged (depending on the location of the pharmacy),
  • arrange for durable medical equipment, and
  • make referrals to outside agencies.

In addition, the extender can support the professional staff and the department in ensuring that the department is compliant with regulatory requirements.

Examples of these tasks include:

  • Deliver the second Important Message to Medicare beneficiaries,
  • deliver Medicare observation letters,
  • provide choice lists for SNFs and home health agencies to the patient/family, and
  • collect choice list when patient/family have completed the choice process.

Extenders can also help with care coordination by:

  • Updating huddle notes as needed, and
  • making initial patient follow-up phone calls.

Extenders should also document where appropriate and necessary. Some examples of appropriate documentation include:

  • Documenting the receipt of the Important Message by the patient,
  • documenting that the choice list was provided and discussed with the patient/family, and
  • documenting that authorization was obtained from a third-party payer and making note of the authorization number.

Responsibilities under the category of utilization management include:

  • Obtaining authorization from commercial insurance companies, and
  • notifying the case manager of requests for clinical reviews.

The extender has to be educated and trained in how to perform these functions and tasks. He or she also needs to be educated in how best to communicate with the case management team. Conversely, the case managers and social workers need to feel comfortable delegating to the extenders. This comfort level comes over time and as the extenders become more proficient in their roles. It is therefore critical that the extenders understand how best to communicate. They should be seen as an integral part of the case manager and social worker team.

Tips for Extender Communication

  • Ask the case manager or social worker when they need to have a task completed, with specific timeframes such as immediately, within an hour, by the end of the day, etc.
  • Update the case manager or social worker on the status of the request if the timeframe cannot be met.
  • Update the patient/family on the status of a referral that has been made.
  • Keep the lines of communication open at all times with the patient and family in terms of the discharge planning process.
  • Communicate the outcomes of any conversations with any team members to the case manager and social worker.

By properly training the extenders and remaining in constant communication with them, they can greatly improve the outcomes of any case management department and pay for themselves many times over.

Case Management Department Mistake Number Five: “Working in Silos”

Despite the healthcare industry’s push toward integration of interdisciplinary care teams, many organizations still remain siloed. This means that they are functioning in isolation of each other, with minimum communication or integration of planning, implementation of the care plan, or management of patient care outcomes and variations from expected outcomes.

Mistake number five is the lack of integration of case management, both vertically and horizontally. Because of case management’s history of coming from utilization review, many case management departments have been slow to integrate themselves as part of the interdisciplinary care team and work apart from, and without integration with, the other members of the team. When this occurs, communication tends to happen only when necessary and in a “reactive” mode, rather than a “proactive” one.

So, who should case management integrate with? Our integration must also happen both within and beyond the hospital walls and should include the following at a minimum:

  • Social workers and RN case managers within the same department;
  • physicians;
  • nurse leaders;
  • staff nurses;
  • ancillary services such as radiology, laboratory and pharmacy;
  • non-acute care providers;
  • senior executives.

Early case management models did not allow for such integration and caused fragmentation of the departments, which resulted in higher cost, poorer integration of care processes, and longer lengths of stay. By the early 1990s, some hospitals began to combine some functions of case management and became “partially” integrated. Unfortunately, social work and RN case managers often remained separated, sometimes in completely different departments. Because the work of the case manager and social worker is so intertwined, this also resulted in less optimal outcomes for the case management department and the hospital.

As we have discussed, today we know that the most effective departments are those that provide for full integration, both vertically and horizontally.

Managing Horizontally

As case managers, you must integrate the work you perform horizontally in the organization. This means that your communication must align with those you work with who are lateral to you. These are your colleagues — they do not report to you, and you do not report to them.

Horizontal communication and integration becomes particularly important as you manage your patient’s care progression. Tests, treatments, and procedures need to be organized in such a way that care does not become delayed or done out of order. Each day that the patient is in the acute care setting must be optimized. This optimization requires careful planning and prospective thinking. When a test, treatment, or procedure needs to be facilitated, it is always best to have a professional relationship with the person in the department with whom you are communicating. So, for example, if you need to facilitate an MRI, having a contact person in that department will make it much easier for you to achieve your desired outcome when necessary. A strategy for making this happen is to have a contact in that department with whom you can communicate regarding delays in care. The case management department should have such contacts in each department with which they interface.

Managing Vertically

In addition to communicating horizontally, you must also communicate and manage those to whom you report, and those who may report to you. This is the process of managing vertically. As case managers, it is our responsibility to keep the manager or director of our department informed of any issues that may require their intervention or knowledge. You should also escalate to your director when you have reached an impasse with a particular issue, physician, or other department. Until you escalate that problem, you continue to “own” it. Sometimes you must communicate an issue to your direct supervisor in order to keep him or her aware of a situation, even though there may be nothing he or she can immediately do about it.

You must also communicate with your physician advisor. The physician advisor’s role is to intervene when you have an issue with a physician or third-party payer that requires a physician-to-physician discussion. As with your director, you should communicate with the physician advisor when you can no longer solve a physician-related problem on your own.

You may also have case management extenders reporting to you. As we have discussed, keep them informed as to the work that needs to get done and hold them accountable for meeting timelines that you have given them.

Next month we will continue to discuss the top mistakes made by hospitals in the design of their acute care case management departments. We will discuss the need to perform your work within specific timeframes, including operating the case management department seven days a week!