EXECUTIVE SUMMARY

Hospitals that still assign case managers to utilization review and care coordination at discharge might consider separating the duties to improve care quality.

  • Utilization management is very specialized work and requires someone to focus on compliance requirements and other details.
  • Case managers could be transitional care coordinators that care for acute care patients, transitioning them to skilled nursing facilities, acute rehabilitation, long-term acute care, home care, and ambulatory care.
  • One key to successfully dividing these roles is to determine which role works best for each person. Some people are more suited to working with insurance companies to reverse denials, while others thrive in working directly with patients.

Utilization management is specialized work that has become more complex over the past decade. Working with patients at discharge and through care transitions also has become a greater priority for health systems due to the Affordable Care Act (ACA) and its focus on the continuum of care and population health.

Some health systems have decided to separate these tasks rather than have one person — usually a case manager — handle it all.

“Since utilization management has become very specialized work, in order to do it correctly and meet all compliance requirements our team decided to separate it,” says Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM, a senior director of care management at Cleveland Clinic in Ohio. Davis also is the immediate past president of the Case Management Society of America (CMSA).

“The primary reason we separated utilization management and case management several years ago is for the benefit of our patients,” Davis says. “The following are under the umbrella of care management: utilization management, social work, transitional care coordinators, and primary care coordinators.”

Transitional care coordinators are nurse case managers. They provide care coordination to acute care patients, transitioning them to their homes, skilled or long-term nursing facilities, acute rehabilitation, long-term acute care, home care, and ambulatory care.

“We have a social worker and transitional care coordinator partnering on one or several units,” she says. “The social worker assists patients that are struggling with social determinants of health, such as food or housing.”

The social worker also addresses other cognitive or behavioral needs, including guardianship and drug or alcohol addiction.

The transitional care coordinator manages the complex clinical transition, coordinating care for patients who are discharged with parenteral nutrition, IV antibiotics, or wound care, Davis says. “Often times, they have to work together to transition a patient.”

For example, an elderly patient who lives with an adult child might be sent home from a hospital stay with IV antibiotics and additional complex care needs. The patient’s child might not be able to handle the patient’s medical needs. The social worker could contact home care and ask for a care assistant or ambulatory social worker to assist, she says.

The primary care coordinator is a nurse care manager who works in the primary care office. He or she receives the patient from the hospital transitional care coordinator and continues to follow the patient-centric plan with evaluation and revisions, as needed. “We also have social workers embedded in the primary care offices. They will assess the patient’s community resources, social situation, and other issues,” Davis explains.

“The point is that we transition the patient. We don’t consider this a discharge — we consider it a transition through and beyond the healthcare system,” she adds.

Transitional care coordinators consider patients’ needs in any community, anywhere the patient might be transitioning.

“We have patients at our main campus from all over the world, but we’re committed to carry out that same model for all patients,” Davis says.

If a patient is from another state, the transitional care coordinator will call providers, such as skilled nursing facilities and primary care providers, in the patient’s hometown. They also might help a patient gain support from family and neighbors.

“We arrange for those transfers to a skilled nursing facility or home care,” she says. “We explain what happened to the patient when in the hospital, and what they’ll need as the next step when they go home.”

When Cleveland Clinic separated utilization management and case management, one key to a successful change was determining which role best suited which team members. For some case managers, working with insurance companies, ensuring cases meet criteria and getting denials overturned, is professionally rewarding. These nurse care managers now can focus solely on utilization management.

Other care managers wanted to spend more time on clinical work. “I was one of those people,” Davis says. “I had worked in an insurance company years ago, but I knew I loved working with patients.”

The utilization care managers can be instrumental in helping transitional and primary care coordinators connect with payers to advocate for patients and, sometimes, to negotiate benefits not expressly written in a health benefit plan.

Care managers across the continuum work with the interdisciplinary teams, which include the patient as the central member. The patient and/or the patient’s caregiver work with the team at every setting to achieve the patient’s goals, Davis says.

“The CMSA Case Management Standards of Practice have always informed my work, and I recommend them to all care managers,” she adds. “Every day is different, but patient advocacy is a care manager’s key standard.”

There are many opportunities to use and enhance this competency across the care continuum.

“Transitional care coordinators huddle with social workers and look at their floor’s census,” Davis says. “Throughput is very important, so their goal is to make sure patients have the right care, at the right time, in the right place.”

They also are involved in interdisciplinary rounds, accompanying the team to patients’ rooms. They ensure patients are part of the care team and goal-making.

“The patient has a critical input into what’s going to happen to him or her,” Davis says.

“When the team visits a patient, the physical therapist might recommend acute rehab to help the patient reach his or her highest functional level. The pharmacist might talk about new medications, and the transitional care coordinator will say, ‘I’ll tell you your choices for acute rehab care,’” she explains. “If the patient’s ultimate goal is to go home, then the transitional care coordinator will say, ‘I’ll do my absolute best to make this happen.’ There may be some steps needed prior to meeting the patient’s goal, but the goal is central through the transitions.”