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The hospital case management role that has been prevalent for more than three decades is transforming, hospital-by-hospital, into a value-based care coordination role.
“Hospital case management, primarily today, is pushing the role of case manager as discharge planner,” says Stefani Daniels, MSNA, ACM, CMAC, president and managing partner of Phoenix Medical Management in Pompano Beach, FL.
“That was never the original intent,” she says. “That occurred because of the hospital financial freefall after the introductions of DRGs [diagnosis-related groups] in the early 1980s.”
When hospitals shifted to cost-based reimbursement to prospective payment, hundreds of hospitals closed, unable to adapt, Daniels says.
“Those that barreled through that tumultuous time believed they could make money if they lowered their length of stay,” she explains. “As a result, in those hospitals where case managers existed, they became intensive discharge planners — get the patient out.”
Hospitals changed case managers into discharge planners and utilization reviewers, she adds.
Another seismic shift began with the Affordable Care Act. This time, the healthcare system is evolving from fee-for-service into a model that encompasses value-based care, population health initiatives, and care coordination across the care continuum. These changes have resulted in community case managers visiting some hospital patients and working with them on transitions to the next level of care or to their homes, Daniels says.
Hospitals that are evolving more quickly with this change are developing a second generation of hospital case management. “In this new marketplace of the accountable care organization, an at-risk payment model of population health, all is dependent on the outcomes achieved — not the value of tasks completed,” she says.
This next generation of healthcare is about care coordination for high-risk patients. The successful care coordination strategy is a complex blend of activities, relationships, and identifying resources that influence the patient’s successful navigation through the system, Daniels explains.
“The transformation of the traditional functional discharge planning-utilization review model is simply an evolutionary adaptation to the new marketplace,” she says.
Hospitals in which executives understand this transformational change will be the 21st century survivors of the shift.
“We need a program that supports the cost-efficient navigation of high-risk patients through the hospital and high delivery system,” Daniels says.
“We need to change from a department to an enterprisewide program,” she adds. “The case management department implies boundaries and specific roles inside that department, while this is a hospitalwide concept — a hospital vision that we’re all responsible for patient care coordination through that hospital system and beyond.”
Hospitals should make this transition soon because community providers are filling the gap, and hospitals’ survival will depend on it, she predicts.
For example, primary care clinics, insurance companies, self-insured employers, and others are hiring case managers to help high-risk patients with care coordination.
“Everyone is jumping on the care coordination bandwagon,” Daniels says. “There is no coordinated effort to make sure we have a single vision for patients. There are patients who report phone calls from three to five different care coordinators, and the care coordinators go into the hospital, working around the hospital coordinators.”
Hospitals are leaving consequential opportunities unanswered.
For instance, the hospital case manager might spend hours on the phone, trying to find a nursing home for patients when this role could be handled more efficiently by someone without a nursing degree. Meanwhile, physicians are ordering duplicate and unnecessary tests for patients, sometimes counter to evidence-based guidelines and the patient’s family’s wishes. This is the type of care coordination situation in which hospital case managers could be of service to patients and actually help to reduce healthcare costs, Daniels says.
Transformation is survival, Daniels explains:
• Reveal the vision. “If you really want to begin the transformation process, you must have a vision first,” she says.
The vision can answer what the hospital means by care coordination.
“You can’t just change the structure and operations unless you have a vision for the future,” Daniels says. “What do you want it to look like?”
When Daniels explains this to health system boards of directors or executive teams, she asks them to envision what they would want for their mother if she were diagnosed with cancer. “What do you expect the healthcare system to do for your mother over the next 60 to 90 days? Do you expect someone to help her understand her diagnosis? Do you want her to know why she gets one treatment and not another? Do you want her to understand what her medications are about?” she says. “Do you want her to understand the choices she has to make?”
The person who can help a patient answer all of these questions is the case or care manager.
The vision is how the healthcare organization will have a single consistent resource for patients. This should be someone the patient can contact throughout the treatment process and while the patient is in the hospital, doctor’s office, or oncology office.
“If this is what you envision, what do you do to make it happen?” Daniels says. “That’s when you talk about structure and operation. I’ve learned that unless you have a consensus on what your vision of case management or care coordination is about, then you’ll float up river against the tide.”
• Consider the culture. “A health system might have an enterprisewide vision that extends across the continuum, but what if its culture is not conducive to teamwork, or what if it does not encourage individuality or decision-making?”
A hospital could have a culture that is so engrained that it is not open with working alongside a case manager. In such a setting, care coordination and teamwork might not work.
“You have to take this into consideration,” Daniels says. “We have to think of the culture of the organization and how it takes a long time to change the culture — like a comic strip of a cruise ship trying to make a U-turn.”
For example, Daniels once visited a hospital and spoke with many employees, including lab and radiology professionals. One person told her about how a physician had ordered 16 CT scans for a teenage boy within the past decade. The teenager had a chronic illness, but the CT scans were excessive and placed him in danger of developing cancer. The radiology professional said, “When I first started seeing a pattern and went to the director, he said that if the physician ordered it, you do it,” Daniels recalls. “So the man learned to keep his mouth shut — no matter what.”
This is a culture of fear, and in this situation, an organization will never work together as a team, she says. “That’s why culture has to be taken into consideration.”
• Adjust staffing. Health systems that make this shift to value-based care with an emphasis on the care continuum often find that their existing case management staffing changes. They might lose one-third of their staff and have to reassign others.
“Most hospital case managers are women and nurses, and many have been enculturated to be deferential to the medical staff,” Daniels says.
When the hospital’s culture and vision change, some case managers might not be able to take on the role of entering a partnership with the physician. The new job requires finding someone who can call the physician’s attention to unnecessary CT scans and serial testing, she explains.
“They have to understand the case manager’s primary ethical obligation is advocacy, and that’s why we lose 35% of incumbent staff,” she says.
• Build multidisciplinary teams. Hospitals can change their structural framework and realign some of their traditional duties, including activities that existing case managers perform, Daniels says.
“We have to make sure the scope of case management services focuses on care coordination,” she says. “That means finding new homes for other things on the case manager’s plate.”
For instance, instead of handling insurance appeals, case managers now work more closely with patients. Their attention goes to the care plan and what makes the patient responsive to therapy.
All of these changes take time and require regular team meetings in which each team member can talk with each other, Daniels says.
In the new accountable care organization marketplace, health systems will have at-risk contracts in which the focus is on outcomes, including patient-centered outcomes.
And one of the most efficient ways to improve outcomes is to have a consistent case manager follow the patient through the care continuum and serve as a single resource for the patient and communicator with the patient and care team, Daniels says.
Financial Disclosure: Author Melinda Young, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher, and Nurse Planner Toni Cesta, PhD, RN, FAAN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.