Toni Cesta, PhD, RN, FAAN is also hosting an AHC Media Webinar on this topic. Click here for the webinar
Last time, we discussed the changing healthcare landscape and how it has caused the field of case management to alter its models in order to respond to these changes. The first acute care models were designed in response to the prospective payment system and the diagnosis related groups (DRGs) payment methodologies. Today’s healthcare environment poses deeper and more comprehensive challenges than were inconceivable in the 1980s. Our case management models of today and the immediate future require careful design with clearly articulated roles and functions for professional and clerical suppport staff. The staffing ratios for these models must allow for the additional roles and functions that are required in today’s acute care setting. These include patient flow, avoidable delay management, outcomes management, and resource management, among others. This month, we will review the elements to be considered when re-engineering an acute care case management model or department.
When designing a case management model, healthcare executives must consider the following:
- Operationalization of the model at the patient level. It must be easy to implement the model at the individual patient level, and patients must be able to realize its effect on their care and outcomes. Some models have been designed in a global, abstract, conceptual sense without any effort to explain how they apply to the individual patient. This leaves the healthcare providers and the case management staff in a struggle, trying to make sense of the model. To eliminate confusion, the conceptual framework of the model must be first redefined at the individual patient or patient care unit level before it is implemented.
- Systemwide perspective. Refrain from implementing a model that does not apply to all services and to the care of the different patient populations served. It is appropriate and acceptable to slightly modify the model to meet the needs of the different services; however, the basic concepts of the model must be maintained regardless of the patient population (e.g., the presence of a case manager in every service or a case manager/social worker dyad).
- Redesign of the administrative, clinical, financial, and quality management processes. Because the implementation of case management models means a change in the patient care delivery processes, it behooves the healthcare executives who design and apply these models to redesign the other processes and align them with case management. The processes affected the most are those related to the role of the case manager: transitional/discharge planning, resource allocation and utilization management, and quality and outcomes measurement. This redesign is important because it determines and ensures cost effectiveness and efficiency in the delivery of patient care.
- Sources of accountability and empowerment. A clear definition of the case manager’s role with identified role boundaries, scope of responsibility, and power is an important factor for success in case management. Case managers who are arbitrarily placed in their roles are set up to fail. Communicating the accountability and responsibility of case managers to all of the departments and staff in an organization is essential for promoting the case manager’s power. One way of achieving this is by explicitly identifying the presence of case management as a department, and case managers as a staff, on the table of organization for every staff member to see.
- Integration of service delivery. Cost savings are achieved by examining the number of departments an organization has and evaluating how each is affected by the creation of the case management model/department. This almost always results in merging and consolidation of departments. If an organization does not merge efforts, fragmentation and duplication will continue and cost savings will not be achieved. The departments affected the most by case management are social work, utilization review, discharge planning, and quality management.
- Measurement systems. Before implementing case management models, it is advisable to have a measurement system in place. The system must include the outcomes to be measured and must identify the process of data collection, aggregation, analysis, and reporting. A prospective approach to evaluating the effectiveness of the model assists in keeping all involved focused. It also prevents mistakes or unnecessary efforts from being made. The outcomes to be measured must always be driven by the goals and expectations of the model. One should maximize data collection from already existing automated systems, such as electronic medical records and data repositories, cost accounting systems, admitting, discharge and transfer systems, and so on.
Re-Engineering the Case Management Department
The list above provides a framework for the beginning of your case management redesign project. The next step should be the development of a planning committee. This committee should be comprised of the hospital’s key stakeholders as well as decision-makers. Members should, therefore, include key physicians, administrators, nursing leadership, case management leadership, and finance department leadership. Other members can be added on an ad hoc basis.
- nurse leaders,
- case management leader,
- social work leader, and
Ad Hoc Members:
- Physicial therapy,
- medical records,
- acute care case manager/discharge planner,
- health education specialist,
- clinical nurse specialist,
- home care intake coordinator, and
- consulting/specialty physicians.
Once the committee is formed, the group should begin to review all the elements to be considered as they begin the re-engineering process. These would include the following:
- cost implications/budget,
- staff (professional/secretarial/clerical support),
- equipment and supplies,
- table of organization,
- hours of operation,
- reporting structure,
- relationships to other departments,
- policies and procedures,
- information technology/systems, and
- educating the organization.
Cost Implications/Budget: Develop a business plan. The plan should include both personnel and nonpersonnel costs needed to run the department. Consider all staff needed, including professional staff and support staff such as secretarial and clerical. Also, consider equipment needs such as fax machines, photocopiers, and computers. Cost this out as part of the business plan. Set up a budget with the annualized cost of running the department.
Staff (Professional/Secretarial/Clerical Support): Staffing should be based on the role functions to be performed. For example, RN case manager-to-patient ratios will be driven by the functions the RN is performing. If the RN case manager is performing clinical coordination/facilitation, transitional planning, and utilization/quality management functions, an appropriate caseload in the hospital setting would be 1:15. For the social worker, the caseload should be 1:17 patients as identified as psychosocially high-risk. For the clerical support staff, consider one support person to every eight professional staff. The number of case managers and social workers needed can then be calculated based on the bed capacity of the hospital. Other staffing ratios should also be driven by the size of the organization and the functions to be performed.
Equipment and Supplies: The time to budget for equipment and supplies is before the implementation while the budgetary costs are being determined. Consider all functions being performed and the hardware and software needed to support those functions. Also, consider the management needs and report writing capability when selecting a software package. Other supplies that should be budgeted for include stationery, paper, telephone lines, transportation, and conferences.
Table of Organization/Reporting Structure: Develop a table of organization for the department with a clearly differentiated reporting structure. Consider where the department will fit into the organization and to whom the director of the department will report. Of significant importance is the case manager: The table of organization must clearly state where the case manager’s position is and to whom he or she reports. This statement is essential for empowering those who assume the role of case manager.
Hours of Operation: The hours of operation of the department may be driven by budgetary constraints. Decisions will need to be made as to whether the department will operate seven days a week, or will function five or six days. Perhaps you will consider having the ED staff working longer shifts (such as 12 hours) while the inpatient staff work eight-hour shifts. Consider the clinical needs of the organization and the goals of the department when making these decisions. If there is a considerable amount of activity on the weekends, plan for weekend operations.
Relationships to Other Departments: The department may have either formal or informal relationships to other departments in the organization. Consideration should be given to how these relationships will be defined.
Policies and Procedures: A policy and procedure manual should be developed and should include all policies and procedures needed to define the functions of the staff. For example, if utilization management is one of the functions of the department, then all appropriate utilization review policies should be included. Consider any CMS, Joint Commission, or state compliance issues when developing the manual. Include the table of organization and the staff job descriptions, training, and competencies in the manual. Also important to have on hand for use by case managers is a resource manual with contact information readily available, particularly for community resources, volunteer agencies, charity and shelter services, transportation services, and skilled nursing/long-term facilities.
Information Technology/Systems: If the budget permits, select computer hardware that is state of the art and that will support the functions you are performing both now and in the future. For example, if one of the goals of the department is to eventually become paperless, be sure that your system will support this goal. In terms of case management software products, try to view and test several products before making your selection. Be sure that the software can store and manipulate all of the needed data, especially variance data, for reporting purposes for the department.
Educating the Organization: Before implementation, set up a series of educational programs. Programs should be conducted for case management staff at an in-depth level and for other staff on a less detailed level. Provide additional focused education to the medical staff and administrative staff as needed. Educational programs should be geared toward the needs of the different nursing, medical, and allied health staff.
Developing the Case Manager’s Role: Careful consideration must be taken when defining the roles and functions of the case manager. Depending on the roles and functions selected, other departments may need to be restructured or eliminated. Match these to the goals and objectives of the department and the organization. If staff members from restructured or eliminated departments are used as case managers, they should be provided with special training. In addition, conducting team-building sessions for these staff members is advisable to work out any concerns they may have. Examples of roles for the RN case manager include the following:
- coordination and facilitation of care,
- utilization management,
- resource management,
- avoidable delay identification and management,
- transitional planning,
- discharge planning, and
- outcomes management.
Examples of roles for the social worker include the following:
- high-risk psychosocial issue management, and
- management of psychosocially oriented discharge planning.
Case Manager Specialty Positions: Another issue to consider is the addition of specialty positions. These might include ED case managers and social workers, a discharge planning specialist to manage the most labor-intensive discharge planning issues, or a perioperative case manager to manage patient throughput during the perioperative phase from pre-admission testing to the post-anesthesia recovery unit.
Integration with Other Departments/Disciplines: In some instances, other departments may become integrated with the case management department. Typically, these may include social work and/or quality management. A physician staff member may also need to be integrated, such as a physician advisor. All related departments should be consulted as these decisions are being made, and appropriate staff should be trained accordingly.
Job Descriptions: Job descriptions should be completed before the implementation of the department. As staff are interviewed and hired for these new positions, they should have an opportunity to review the job description and expectations for the position for which they are interviewing. Be sure to include all job functions, skills, performance expectations, and expected outcomes of the position. A job clarification exercise is usually helpful in determining who is best suited to assume responsibility for what functions.
Service Line vs. Unit-Based: The case managers can be assigned to specific product/service lines or clinical areas or be unit-based. They may also be assigned to physician groups or geographical areas, depending on whether your department is in the hospital or in the community. This decision will ultimately drive your staffing patterns and needs. Decisions must be made carefully because of their effect on performance, productivity, and the possibility of ending up with unnecessary unproductive time such as travel time between units, departments, or different locations.
Reporting Structure: A strong infrastructure is important to the success of a case management department. Be sure that the case managers have a clear line of authority and are well-supported as they perform their functions.
Staffing Patterns/Case Loads: A typical mistake made when designing case management departments is to not provide the proper staffing patterns to support the role functions selected. Be sure that the caseloads are not so great that the case managers cannot perform their functions effectively or efficiently. This will surely be a formula for failure. Staffing patterns should also depend on whether you go with service line case managers or unit-based case managers, patient acuity levels, and length of stay.
Hours of Operation: Select hours of operation that best meet the operational needs of the department and the patients. Increase the number of staff at busier times, and decrease the number of staff at quieter times. Consider evening, weekend, and holiday needs. Hours of operation should be adjusted to the needs of different care settings and patient populations.
Variances/Avoidable Delays: A variance identification system should be developed before implementation. Categories of variances such as patient, family, internal systems, external systems, and provider should be selected, as well as a methodology for collecting, coding, aggregating, analyzing, and reporting of variances.
Documentation: Frequency of case management documentation and expected content should be determined and included as a policy and procedure for the case managers. Each organization needs to determine its own specific expectations for documentation. The initial admission assessment can be a standardized form that should be completed on the day of admission. The discharge summary can also be in the format of a standardized form.
Orientation: Curricula for orientation of case management staff, other departments, physicians, and administrative staff should be developed, and education should take place before implementation. This will ensure greater organizational support because the reason for the changes will be understood by all involved.
Goals and Objectives: Departmental goals and objectives should be identified before implementation and included in the educational programs. The goals and objectives selected should be consistent with the vision and mission of the organization. These may include measures of cost such as cost per day/cost per case and measures of quality patient outcomes. All should be prospectively identified and should drive the evaluation of the program.
In the last two issues, we explored the hows and the whys of re-engineering an acute care case management department. Remember that the models and methods of the past are probably not enough to move your organization into the new era of healthcare.