Introduction

In the last two installments of Case Management Insider, we reviewed the first four of the top 10 mistakes that you may be making in your case management department. We discussed roles and functions, best practice models, staffing ratios, and clerical support issues and opportunities for improvement in your department. This month, we will be discussing three more of the top 10 mistakes that your department may be making and how to potentially improve or eliminate them.

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

Another common mistake often made in case management departments is to operate the department in an isolated fashion, with poor or no integration with other members of the interdisciplinary team and/or other departments. There is a variety of ways in which case management can be integrated within the hospital organizationally and culturally. Integration is an important component for success and must happen throughout the hospital. By having strong formal and informal relationships with other departments and disciplines, the case management department will be better prepared for successful outcomes across the organization. There are teams and committees that can provide a strong foundation for good communication.

• Case Management Steering Committee

• Readmissions Reduction Team

• Hospitalist Team

• Denials Management Team

• Patient Flow Committee

• Medicare Spending Per Beneficiary Efficiency Team

• Long Length Of Stay Team

• Patient Financial Team

• Compliance Team

• Case Management Practice Team

• Interdisciplinary Rounding Committee

While we can’t go into detail on each of these teams and committees, I will highlight those that will provide the greatest return to the case management department if implemented and used properly.

The Case Management Steering Committee

This group may be one of the most important teams that a case management department will have. Whether you are re-designing an existing department or have an established department, the steering committee can provide an important function in assisting the case management department in achieving its desired outcomes. The steering committee should be a working committee that meets regularly to discuss issues relevant to the case management department, but also to any departments or disciplines that interface with case management. As we know, this is virtually any department in the hospital. The committee should be made up of members who have the authority to make decisions in the organization, so it is a high-level group.

The roles and purposes of the team include the following:

• Interdisciplinary leadership oversight of case management initiatives.

• Obtain input from leaders involved in case management processes.

• Focus on interdisciplinary team integration in processes related to case management.

• Assist in making recommendations for improvement in the case management department.

The committee should consist of the following members or their representatives. This is the minimum membership. Others can be added as needed, or invited on an ad hoc basis. Remember that committees work best when small; between six and 10 standing members is optimal.

Team membership can include the following:

• Executive team sponsor

• Case management leaders

• Nursing leadership

• Ancillary services leadership

• Patient access

• Finance

• Physician leader

• Hospitalist leader

Listed below are some of the activities that might be assigned to this committee:

• Develop, evaluate, and improve interdisciplinary processes related to case management initiatives.

• Develop and update/review walking around processes.

• Review dashboard and identify areas for improvement.

• Discuss role of case manager on the unit.

• Receive input regarding updated or changed case management model, roles, and/or functions.

• Plan for family meeting or patient care conference process.

• Discuss regulatory changes affecting case management, e.g. the two-midnight rule.

The Readmissions Reduction Team

As the Centers for Medicare & Medicaid Services (CMS) continues to add diagnoses to the list of those they are monitoring for 30-day readmissions, and as the percent penalty to Medicare billing continues to rise, it is important that every hospital have a dedicated team that is actively working on reducing the hospital’s readmission rates. Even if the hospital has not yet received a penalty on their rate of readmission from CMS, it is imperative that yours stay ahead of the curve. Like most of the CMS metrics, this one is a moving target and changes as hospitals continue to improve their performance in this area. This means that as other hospitals improve, so must yours.

The roles and purposes of the Readmission Reduction Team include the following:

• Oversight of the CMS readmission metrics.

• Preparation for future changes to the metric, such as the addition of diagnoses.

• Development of hard-wired processes to support readmission reduction.

Team membership:

• Case management

• Nursing

• Emergency department leadership

• Post-acute providers

• Physician leadership

• Primary care leadership

• Primary care physician leaders

• Quality

As you can see, this team includes many leaders from beyond the walls of the hospital such as those in the primary care and post-acute areas. While case management can make many changes that will contribute to a reduction in readmissions, complete success will be dependent on including leaders from these other areas. Since patients return to the emergency department (ED) from any of these locations, strategies to reduce returns to the ED and potential readmissions are critical to the success of this team.

The team should review readmissions in an effort to identify patterns such as higher-than-average readmission from a particular nursing home or home care agency. Other activities should include interventions that should be performed in the emergency department or outpatient area, rather than readmitting the patient. An example of this might be a clogged PICC line.

Medicare Spending Per Beneficiary Efficiency Team

Another strategic and important group would be the committee assigned with monitoring the Medicare Spending Per Beneficiary metric, also known as the “efficiency measure.” This metric monitors hospitals in their performance in length of stay and cost for selected diagnoses. Poorer than average performance means a financial penalty to the hospital. This measure involves spending that occurs three days before admission and follows to 30 days after discharge. Therefore, as the readmission reduction committee had to have representatives from beyond the hospital walls, this team should be structured in the same way.

Roles and purposes of the Medicare Spending Per Beneficiary Team (MSPB) include the following:

• Optimize and improve the MSPB metric.

• Understand the impact of the measure on the hospital.

• Create working teams to address areas of vulnerability.

Team membership:

• Case management

• Nursing

• Emergency department leadership

• Post-acute providers

• Physician leadership

• Primary care leadership

• Primary care physician leaders

• Quality

Examples of activities for the MSPB Team include the following:

• Review metrics on www.medicare.gov/hospitalcompare.

• Identify trends, both negative and positive.

• Create sub-teams to reduce resource consumption and length of stay in targeted areas.

• Review quality performance of post-acute providers in terms of cost and readmission rates.

Case Management Department Mistake Number Six: “Untimely Assessments and Interventions”

Mistake Number Six relates to the timing of the work within the case management department. As lengths of stay continue to shorten, timing of the work of the RN case manager and social worker is another key component for success. Gone are the days of assessing the patient within 72 hours of admission. Even 48 hours is much too long. Just as the staff nurse and the physician assess the patient on the day of admission, so should the RN case manager. By obtaining the initial assessment on the day of admission, or within one business day, you can use the information you collect to do your clinical review and begin the discharge planning process at the same time! This is a time saver and makes your work process more efficient.

Strategies for managing patient information in a timely manner:

• Each day, every new admission must be identified.

• If the patient was transferred to you from another unit, be sure you get hand-off communication from the prior case manager.

• If you are transferring the patient off your unit, be sure to include a written summary and provide a verbal hand-off to the receiving case manager.

Sharing timely information between and among case management staff is an important tool for effective communication and reduction in time delays. Once a new admission has been identified, the admission assessment process must begin. As already mentioned, this assessment should be done on admission in the majority of cases. Strategies for completing the assessment include the following:

• Review the patient’s current and prior medical records.

• Interview physician.

• Interview patient and family.

• Complete admission assessment tool.

Another key strategy is to use a standardized admission assessment tool. Not only does this expedite the process, but it also ensures that all data is collected in a standard format and that data elements are not omitted. This is a very short sample of the data elements that should be included:

• Information obtained from patient/family/ED/prior medical records

• Patient gave permission to complete assessment and discuss discharge plan with _________

• Information obtained via_________

• Primary contact

• Special needs

• Living situation

• Type of housing

• Stairs

• Elevator

• Requires assistance

• DME used prior to admission

Here is the process outlined for the day of admission:

Step 1: Review the current medical record, including all relevant diagnostic test results, such as lab values and radiology reports.

Step 2: If the patient was admitted through the emergency department, review all available EMS notes.

Step 3: Obtain and review prior medical records if available.

Step 4: Discuss the patient with the admitting physician.

Step 5: Interview the patient and/or family.

Daily Assessments

In addition to seeing and assessing new patients on the day of admission, it is also critical to see your patients each and every day they are assigned to you. A daily review of your patients will ensure that you are up to date on their clinical progression. By updating this information daily, you will also be able to assess whether your discharge plan is still accurate and timely. Daily assessments can take many forms. The most efficient method is through the use of interdisciplinary walking rounds. It is during rounds that you will be able to see your patient and also hear updates from the other members of the patient’s care team. The exchange of information that takes place during rounds can be comprehensive and quick, when done properly. Seeing a patient visually, as well as speaking to them, gives you a tremendous amount of information very quickly. Of course, this needs to be supplemented by the information from the other team members and an update of any diagnostic test results or other information to inform the continued stay of the patients.

Daily documentation should include the following elements:

• Any updates to the patient’s social, financial, or family situation.

• The status of the discharge plan.

• The completion of any compliance tasks such as the “choice list.”

• Any barriers to the completion of the discharge plan.

• The status of any referrals made.

• Any legal issues, such as guardianship or immigration status.

• Any patient education needs.

When it comes to timeliness in today’s contemporary case management departments, it is imperative that patients are seen in a timely manner and on a daily basis. This is a critical and important element of success.

Case Management Department Mistake Number Seven: “Five-Day-a-Week Department”

Number seven on our top 10 list is the frequent mistake of running the case management department on a five-day-a-week schedule. When case management departments were originally utilization review-only, five-day-a-week coverage worked and made sense. Today, however, we need to consider all the additional roles and functions that case managers perform that require additional coverage. For example, patient flow requires seven-day-a-week diligence, as patient length of stay needs to be optimized each and every day that the patient is in the hospital. The same logic would apply to discharge planning and the movement of patients out of the hospital, which should also occur seven days a week.

Additionally, patient admission assessments should be completed seven days a week, as well as reassessments. Even a skeleton crew working on the weekends cannot accomplish all of this. Therefore, it is recommended that the weekends be staffed at least 50% of the weekday staffing levels. Weekend staff should have a clear understanding of the scope of the work they are required to perform. The work should not vary depending on who is working on a particular weekend, but rather should be consistently applied by all staff. If you are running the staff at 50%, then staff can double up, covering two units on the weekend. Because admissions and discharges are usually somewhat slower than weekdays, it is more reasonable to expect that assessments, discharge planning, and patient flow activities will be able to be accomplished over the course of the weekend.

By smoothing the workflow across seven days, your department can prevent delays and excessive work on Mondays and days after holidays. These workloads result in delays that can stretch into the middle of the week at times and result in the staff constantly playing catch-up.

Other Areas to be Staffed

Another key area to be staffed aggressively is the ED. For all the reasons listed above, consider staffing the ED seven days a week as well. Also consider 12-hour shifts in the emergency department. Twelve-hour shifts allow for maximum coverage during peak hours there. You can also stagger the work hours between the RN case manager and the social worker to maximize the coverage in the ED.

If you have an access point case manager in the admitting area, this position can safely operate five days a week with coverage by the ED case managers on the weekends as needed. The denials and appeals staff can also work five days a week without compromising the work of the department.

Leadership staff should consider working at least one weekend day a month. This is a good way in which to get a feel for how the work is getting accomplished on the weekends and where issues or opportunities might lie.

As discussed in a prior issue, today’s case management department should include clerical support staff. These staff should also operate on a seven-day-a-week schedule. This may be even more crucial if you are running a 50% staffing pattern on the weekends or even a skeleton staff on weekends. Clerical staff can support the work of the professional staff and remove weekend time wasters that will reduce their chances of completing all the work that we have listed above that requires the attention of the professional staff on the weekends.

Finally, consider “vacancy” coverage. Vacancy coverage refers to staff that are not routinely assigned to a unit but “float” where needed. These positions can cover for holidays, vacations, sick time, and any other reasons that staff may be off.

Summary

This month, we reviewed three additional mistakes that are commonly being made in case management departments in hospitals today. Next month, we will review the final three of the top mistakes that you may be making in your department.