INTRODUCTION

Last time, we reviewed the roles and functions of the RN case manager and the social worker in today’s contemporary case management models. As we discussed, standardization is key to the success of any case management department. Budgets are tight these days and, while there are standard roles and functions for any department, there are ways in which the department also can be creative and thoughtful in designing additional roles that may better meet the needs of your hospital as well as the population of patients you serve.

This month, we will discuss some new and creative ways to use the staffing within a case management department, but let’s be clear: You still need to have the foundational positions discussed last time. The creative elements come in when you need to address other issues or needs within the department. The goal is to optimize the resources you have at hand and to think outside the box whenever you need.

Once you have established your foundational positions, including the roles and functions associated with them, you can begin to identify where gaps may be located. You may need to shift resources in order to adequately manage the workload and to achieve the expected outcomes of the department. Ask yourself the following questions:

  • Do I have a clear demarcation as to who does what?
  • Do I have the resources in the right places?
  • Do I need specialized roles to support the foundational positions?
  • Have I adequately covered my entry routes to the hospital?
  • Do I have a large number of long-stay patients?
  • Do I have a large surgical service, including ambulatory and inpatient surgeries?
  • Is my transitional process for patients as tight as it could be?
  • Do I need an in-house physician advisor?
  • Is my leadership team adequate to meet the needs of the department?
  • Does my health system have community-based case management?
  • Do you have trouble keeping your staff up to date on regulatory and other issues?
  • Do you have difficulty orienting and managing new hires?

If the answer to any of these questions is yes, then you may want to consider one or more of the following positions. Even if you haven’t answered yes to any of these questions, you may still have identified an area of opportunity for your department. Each position carries pros and cons. The most significant con is always the cost of the position weighed against the value added by the position.

Access Point Case Manager

Within the role of access point case manager are two distinct roles: the ED case manager, and the admitting department case manager. Let’s review each of these positions so you can evaluate whether you need to have one or more of these in your department.

The ED case manager and the admitting department case manager positions are in the category we will call access point case management. These positions are designed to manage and control the types of patients and the levels of care approved for admission to the hospital. They also provide for alternative care when needed and appropriate. Through the access point case management roles, the hospital has a greater level of assurance that their patients are placed in the right level of care to ensure greater reimbursement. The admitting department case manager provides gatekeeping functions for the following types of patients:

  • planned admissions,
  • urgent admissions,
  • direct admissions, and
  • transfers.

The admitting case manager works directly with the admitting department staff to review all but emergency admissions. On some occasions, these patients may be appropriate for placement in observation rather than an admission. The admitting case manager may also see some patients during presurgical testing to begin the case management assessment process, and/or to begin the discharge planning process. These patients are usually surgical, planned admissions.

The ED case manager has responsibility for patients presenting to the ED. This position has become increasingly important with the advent of the Two-Midnight Rule via CMS, as this position plays an important gatekeeping role for emergent patients. The Two-Midnight Rule requires that patients be placed in observation if the physician anticipates the patient will not remain in the hospital for more than two midnights. On these occasions, the patient should be placed into observation. During the period of observation, the physician can gather additional information and make a determination as to whether the patient needs to be admitted to the hospital or can be discharged from observation. The ED case manager reviews patients after the physician has determined that the patient must be kept in the hospital but before a status determination is made. Through this review, as well as discussions of the plan of care with the physician, the patients can be placed in observation, admitted to the hospital, and discharged from the emergency department. This is an integral and key process needed to maintain compliance with the Two-Midnight Rule and to reduce the level of denials for Medicare patients.

In addition to this important function, the ED case manager is responsible for coordinating and facilitating patient flow in the ED by ensuring that tests, treatments, procedures, or consults are performed in a timely manner. This process helps to manage length of stay in the ED and to expedite discharges when appropriate. When transitioning home from the ED, the case manager can prepare a discharge plan that meets the patient’s needs, including the possibility of home care. This process can reduce the number of inappropriate and unnecessary hospital admissions. The ED case manager may also begin and/or complete the clinical review process in sending information to a third-party payer. If not completed in the ED, this function helps reduce the workload for the unit-based case manager. Finally, the ED case manager may work with the ED physician to reduce overutilization of resources such as tests, treatments, consults, or procedures.

If your hospital admits less than 60% of your patients via the ED, you may want to consider a shared role if the budget does not allow for both positions. If more than 60% of your admissions enter via the ED, you should seriously consider having both positions. In other words, depending on the routes of entry, ED and admitting might be a shared role if smaller numbers are admitted via the ED, or two roles if greater numbers of patients are admitted through the ED.

Perioperative Case Manager

If your hospital has a significant surgical program (at least 20 inpatient beds), then you should consider the perioperative case manager position. Depending on the volume of ambulatory surgical patients in your hospital, this position might manage these patients as well. The position is responsible for patients as they transition from preadmission testing until discharge from the post-anesthesia care unit (PACU). It is during this process, as well as before, that the case manager continuously ensures the patient is in the right status postoperatively such as extended recovery, observation, or inpatient admission. The perioperative case manager provides clinical coordination and transitional planning across the continuum of the patient’s surgical or perioperative process. This position works to identify and remove barriers that might prevent or slow the patient’s progress through the perioperative phase of care. This would include identification of barriers during the preoperative process as well, particularly those that might result in cancellation or delay of the surgical procedure.

The periop case manager coordinates care in concert with physicians, nurses, patients, and families, ensuring a smooth and safe movement through the periop process, including discharge from the PACU. The case manager may make referrals to home health, sub-acute, or acute rehabilitation as needed, providing pertinent information to these post-acute providers. Finally, the periop case manager should provide a report to the next case manager, ensuring the handoff communication includes a verbal, as well as written, process.

Transfer Center Case Manager

The transfer center case manager is responsible for transfers into and out of the hospital. You may want to consider this position if your hospital conducts a large number of transfers in or out of the hospital. If you do not perform a lot of transfers, you may want to consider combining this position with the admitting department case manager. Let’s begin with a discussion of the management of the transfers into the hospital. The transfer center case manager reviews patients for medical necessity, including both the level of care and the status, for any patient transferred into the hospital for any of the following areas:

  • inpatient acute care,
  • inpatient rehabilitative care,
  • long-term acute care, and
  • skilled nursing facility.

The person in this position must have a working knowledge of EMTALA rules and regulations so patients transferred from outlying hospital EDs are handled appropriately and legally. They serve as a liaison between sending hospitals and case managers on the accepting hospital’s units for communication regarding medical necessity and any communication between transfer center case manager and accepting physician. They ensure there is authorization for any patient transferred in who is out of network (unless EMTALA applies). They work to facilitate a timely acceptance of patients transferred into the hospital, and work with the admitting department to identify any non-EMTALA patients to ensure that there has been an accurate assessment of benefits.

When time allows, the transfer case manager may review any documents from sending hospitals. When possible, this should include uploading the patient record so the transfer center case manager can review the record and perform the initial review of medical necessity while the patient is transferred. Finally, for any patient that is on the transfer waiting list, the case manager should review documents to assess medical necessity and any potential discharge planning needs.

For transfers out of the hospital, the case managers coordinate applicable EMTALA rules and regulations. They review required state forms for appropriate completion. They ensure authorizations for any payer requiring this, usually for higher level of care or services not provided in hospital. Finally, they participate in any collegial discussions with hospitals or other entities transferring to your system’s facilities.

Complex Discharge Planning Specialist

If your hospital has at least 15 to 20 patients on any given day who require intense and complex discharge planning, then you may want to consider this position. While the complex discharge planning specialist can be a social worker or RN, the position is usually filled with a social worker experienced in managing difficult-to-discharge patients. The purpose of this position is to free up the staff case managers and social workers from these time-consuming patients, and have the patients’ discharge planning needs managed by a specialist who works intensely on these patients.

The focus for the position can be patients who have exceeded a predetermined length of stay threshold, or it can be patients whose discharge planning needs are so intensive that they may divert the staff from managing and moving the more routine patients. The patients are assigned to the specialist who continues to work with the nurse case manager as a dyad.

Physician Advisor

The physician advisor has become a must-have for most case management departments. While some hospitals have opted to outsource this function, many continue to retain an in-house physician advisor. The physician in this position can be full-time or part-time, depending on the needs of your department. The physician supports the clinical review function of the case management department regarding the medical necessity of patients. He or she may meet with case management and healthcare team members to discuss selected cases, and may be called on to address specific attending physician issues when there are delays in throughput or discharge, or when there is a discrepancy in the ordered status of a patient. This role has become particularly important in supporting compliance to the Two-Midnight Rule. The physician advisor may chair the utilization review committee and support resource utilization and other issues around length-of-stay management. Many of these functions are difficult to perform via an outsourced process.

Community Case Manager

The acute care case manager can no longer work in isolation, disconnected from community-based providers. For some patients, this may mean connecting these patients to a case manager who will assist in managing their care outside the hospital setting. Based in a community setting such as a patient-centered medical home or clinic, the community case manager follows clinically high-risk patients who score high on a risk stratification scale. Patients selected for case management in the community may be those who have a chronic condition that places them at risk for poor clinical outcomes, visits to the ED, or readmission to the hospital. They work with patients, doctors, and nurses involved with patient care to promote adherence to the medical care plan.

When necessary, the RN case manager will deploy a community outreach worker to provide home- or community-based support to further enhance the patient’s compliance to the medical care plan (e.g., assistance getting to/from appointments, obtaining medications from pharmacy, etc.), or engage patients who do not respond to contact attempts.

Other roles for the community case manager include use of the patient registry to monitor patients’ compliance with medical and lab appointments, and reach out to remind patients of upcoming appointments. When appointments are missed, the RN case manager will assist with rescheduling and maintaining future appointments.

Social Work Community Case Manager

The social worker follows psychosocially complex behavioral health or substance abuse patients who may also be followed by the RN community case manager for their clinical needs.

He or she works with patients and various community providers, as determined by the patient’s psychosocial needs, to address nonmedical needs that may impede adherence to the medical care plan.

Like the RN case manager in the community, when necessary, the social worker will deploy a community outreach worker to provide home- and/or community-based support to further enhance the patient’s compliance to the medical care plan, or engage patients who do not respond to contact attempts.

Transitions Case Manager

The transitions case manager can be an important role in the management and reduction of hospital readmissions. As CMS continues to add conditions to the readmission penalty list, a position of this type will increasingly become important to hospitals that continue to have high readmissions. The transitions case manager follows high-risk patients while in the hospital and during the first 30 to 90 days after discharge, depending on complexity and adherence to the medical plan. The patients are followed telephonically with linkages to primary care providers, home care, and others as needed. Their focus may be on frequent readmissions as well as specific diagnoses, particularly chronic conditions.

Director of Case Management

The following titles for the case management department leadership may need to be adapted to the titles in your organization. The director is the highest-level leadership positon in the department and is responsible for the day-to-day operations of the department including hiring and firing, budget, staffing, and evaluations. The director is expected to monitor the department’s outcomes through maintenance of a case management report card or dashboard. The director reports to a senior leader in the organization.

Manager of Case Management

The manager of case management is the second in command and is in charge of the department in the director’s absence. He or she serves as the direct report for the staff and assists with performance evaluations. The manager also maintains correct staffing ratios on a daily basis.

Educator of Case Management

If your department is having trouble keeping staff current on new regulations, and/or orientation and precepting new staff, you may want to consider this position. The educator is responsible for orientation of new staff in concert with unit-based preceptors and evaluates the orientees, provides monthly educational updates to staff and leadership, and provides education related to departmental software as needed.

Supervisor of Case Management

Depending on the size of your department, you may need to have a supervisor who reports to the manager of the department. The supervisor provides day-to-day support to the manager and may occasionally take an assignment.

Our final role is that of the team leader. This is a staff RN or social worker leader who has a patient assignment and provides mentoring and/or preceptorship to staff. This position can be used as a career ladder opportunity for staff as well.

Summary

The titles listed above should provide you with some ideas for creative staffing for your own department. Remember to think about your gaps and be creative as you explore new options.