Once upon a time, a hospital’s case manager performed all case management responsibilities and utilization review work. Social workers performed a lot of the discharge planning. All worked fairly well, but something was missing: Case managers were limited in their ability to care for patients.
The hospital changed its model to a unit-based approach in which case management was divided into the utilization review segment and the case management piece, says Tamara Crawford, RN, MSN, manager of clinical research management at Riverside Healthcare in Kankakee, IL.
“Now, case managers do professional care, working with physicians; social workers do psychosocial counseling and have meetings with patients, families, and physicians; and utilization review is a separate department within resource management that does all utilization reviews,” Crawford explains.
Prior to the switch to a unit-based model, the health system tried a physician-based model, and some staff had concerns with this, says Mary Schore, RN, MSN, CPHQ, CPPS, director of quality improvement at Riverside Healthcare.
“We were hearing from nursing and case managers that they preferred the unit-based method because they could build relationships with nursing staff on the units, and the case managers could build it with nursing staff on the units,” she says.
Utilization review specialists cover 24 hours a day, seven days a week in the health system.
The case management department makes referrals to skilled nursing facilities, home health, etc., and there are several post-acute care coordinators. They also work with patients, staff, and families to help with the progression of care for the patient. These in-person meetings include an assessment of patients and collaboration with physicians to determine the right level of care for the patient, Crawford says.
“Then they do discharge planning, making sure the patient is discharged to the appropriate level of care and taking into consideration the patient’s choice,” she adds.
Social work specialists provide psychosocial counseling. They also work with patients and families, staying involved in family meetings, Crawford says.
“If they need home healthcare, case managers, social service, and nursing units on the floor can call this department, and the post-acute care coordinators will fax out information and make the referrals, depending on patient choice,” Crawford says.
Utilization review specialists review patients and observe them to make sure they’re receiving the right level of care. They complete all of the insurance reviews in hospitals and work on appeals and denials, she says.
“Access utilization review is in the emergency department,” Crawford says. “They use specific criteria as a guideline and actually review patients when they come in to determine their status, to observe, and to suggest and work with emergency department physicians.”
Care coordinators are responsible for taking phone calls to make sure referrals get out appropriately and to touch base with the facilities, she says.
“Sometimes, care coordinators will talk with the nursing staff, letting them know what’s going on, and they make referrals while the patient still is in the facility,” she adds. “Care coordinators make sure there is a bed in a skilled nursing facility, and they call case management staff to let them know about the care transition.”
What used to be two departments now has these five subgroups: case management, social work, utilization review, access utilization review, and post-acute care coordinators, she says.
“All of access utilization review staff members are registered nurses and utilization review employees are also, but post-acute care coordinators are not nurses,” Crawford says.
Some post-acute care coordinators have advanced college degrees, but this is not a requirement, she says. Training is individualized.
“We separated case management and utilization review,” Crawford says.
Nurses perform medication review, several people were assigned the role of utilization review specialists, and there are more than a half-dozen each of case managers and social work specialists. There also are access utilization review staff and several full-time care coordinators.
“We had to have administrative approval to expand this area to improve the services we were providing,” Schore says.
The model change and division of duties were necessary to improve quality care, Crawford and Schore say.
“It’s difficult for a case manager to do it all, and that’s probably why they’re separating these roles,” Schore explains. “It takes a lot of time to be on the phone with the insurance company and waiting for callbacks.”