At McLeod Regional Medical Center in Florence, SC, a multidisciplinary team created a “model cell” where case management best practices are adapted to meet the needs of the hospital and where new employees receive their training.
“The model cell operates the way we want the case management process to work on all floors. It helps us work the kinks out of best practices and to create standard processes to be used throughout the hospital,” says Reeana Henderson, RN, associate vice president of case management for McLeod Health.
The goal is to eventually use the model cell to implement model floors throughout the organization, Henderson adds.
The team created the model cell using an operational Lean process with a goal of clarifying case management roles and providing consistent assessment and discharge planning throughout the hospital, Henderson says. “We have worked on every aspect of the case management process, sometimes more than once,” she says.
The 461-bed facility, the flagship hospital for McLeod Health, has three towers, with a case management manager assigned to each. The case management department was reorganized in 2016, shifting from a triad model to dyad model. An average of 28 case managers are on duty on any given day and each has an average caseload of 15 patients. A total of 16 social workers cover the hospital.
The department also has seven extenders who help with clerical work, and three nurses who work remotely with the utilization compliance team on concurrent denials and peer-to-peer secondary review.
“When we changed models, people quickly went back to their old way of doing things. The nurse case managers and social workers were struggling to follow the new model. The responsibilities were clear and well-delineated, but the staff was not seasoned enough to completely understand their role,” Henderson says.
The triad model had three separate and distinct roles: RN case managers, social workers, and utilization review nurses, Henderson says.
Now, under the dyad model, case managers are responsible for assessments, care coordination, utilization review, and discharge planning. The social workers handle the psychosocial issues and partner with case managers on complex discharge planning.
The case management team began its Lean initiative on the hospitalist floor. “The hospitalists had moved to geographic rounding which made it easier to develop a model floor and have everybody buy in,” Henderson says.
Members of the Lean team included Henderson, the case management managers from nursing and social work, the manager of the operational effectiveness staff, the case managers, a social worker, and an extender who are assigned to the floor. All of the team members have completed Lean training.
When the team reviewed long-stay patients, they found that many of the issues delaying discharge were at the front end, Henderson says.
“Much of the staff was new to case management and there was not a good training process. As a result, the assessments were not consistent, the transitions were not going smoothly, and there was not a specific process for the staff to follow,” she says.
One of the objectives of the project was to clarify all the roles so everyone in the department would be clear on who is doing what, where documentation takes place, who is responsible for each day-to-day task, and how multidisciplinary rounds should be conducted, Henderson says.
When the team developed a new process or recommendation, they tested it on the model cell.
The hospital is rolling out the processes created during the Lean pilot throughout the hospital this spring, making minor changes on individual floors based on the types of patients and processes.
As part of its ongoing improvement work, the case management department created a referral placement center staffed by extenders who work on placements in skilled nursing facilities, assisted living facilities, and swing bed facilities.
“In the past, social workers and nurses all over the building were sending placement queries all day. Now with the work centralized in the referral placement center, it saves staff time and a lot of calls,” Henderson says.
One of the biggest projects for the team was creating an electronic dashboard that gives the staff all over the hospital an instant view of what is going on with each patient.
The dashboard, created by modifying the hospital’s teletracking patient flow tool, helps the staff manage patients’ daily improvement. For instance, if the case manager determines that a patient no long meets medical necessity, the patient’s slot on the dashboard turns red.
“This helps with patient flow by alerting the staff when patients need to be moved from a unit. If there are a significant number of patients who need to be moved to another level of care, the case management manager knows that the case manager on the unit may need extra help,” Henderson says.
There are tabs to alert the referral placement center when patients will need a post-acute placement. The dashboard also lets the staff know when a discharge is pending and when a bed is available. There is a box that shows if the Important Message from Medicare has been delivered.
“We use the teletracking tool to help with a variety of tasks and it also helps us identify where case managers may be struggling,” she says. After the team worked out the glitches in the teletracking process in the model cell, the hospital rolled it out to other floors.
The team also developed a daily improvement board that hangs in the nursing break room that cites three goals each month. One of the goals is to discharge 50% of patients by 1 p.m.
“The goal of the Managing for Daily Improvement initiative is for everybody — the case managers and the nursing staff — to take ownership for what happens on the unit. The staff is responsible for going over the board every day before afternoon rounds and noting their progress toward the goals,” she says.
The department also has instituted mandatory daily interdisciplinary rounds and created a format for the staff to follow.
When the rollout is completed, each unit will have multidisciplinary rounds in the morning and afternoon rounds to discuss what is likely to happen the next day. In addition to the case management staff, the multidisciplinary rounds will be attended by the hospitalists, nursing representatives, and representatives from other ancillary services that are part of the care team.
When new case managers are hired, they go through training in the model floor. “Instead of working with preceptors who have no formal training, they spend time on the model floor. This way, everybody has the same training,” she says.
Many of the department’s new hires do not have case management experience, but they do have expertise in the area for which they will be assigned, Henderson says. For instance, if there is an opening on the surgical floor, Henderson looks for a nurse with experience in a surgical area and who has the collaborative and critical thinking skill set. “It’s essential for case managers to be people who can take ownership of things,” she says.
New case managers spend a week with the staff development coordinator and then spend four to six weeks on the model floor, working with one of the nurse case manager before going to their assigned floor. Then, they undergo 30-, 60-, and 90-day competency checks.
Henderson and her team have collected data from every floor in the hospital and are using it to create a staffing chart that bases each unit’s staffing on the workload.
“We were staffed at 1 to 15, but no one took into account that some floors are busier than others. For instance, the surgical floor typically has 12 admissions a day while other floors may have four admissions,” she says.
The team pulled data for each unit and analyzed the number of admissions and transfers in and out each day. They calculated the average time it took to complete an InterQual assessment and other tasks case managers performed each day to get a picture of the work process of each unit.
“The data will enable us to base staffing on each floor on what the patient population is like on the floor,” she says.
For instance, the surgical unit has more admissions on Tuesday and Wednesday. On another unit, a significant number of patients are discharged each day.
“We are analyzing data from throughout the hospital to determine if we need to change the way we assign duties,” she says.