The National Academy of Medicine (formerly the Institute of Medicine) opened the healthcare industry’s eyes to the issue of overtreatment. Excess screenings, scans, and treatments that offered little or no benefit were being prescribed at an estimated $210 billion a year, according to a 2013 report. (The report is available online at: https://bit.ly/2VrevSs.)

In many cases, this practice stemmed from the physician’s fear of malpractice, or to meet hospital performance measures. Many patients during that era felt that “more care is better care” and pushed for tests and scans to confirm earlier findings.

“We had so much technology, and put our confidence in it,” says Vivian Campagna, MSN, RN-BC, CCM, chief industry relations officer for the Commission for Case Manager Certification. “We were double-checking to be absolutely sure, but along the way lost sight of the cost.”

Today, hospitals continue to grapple with the issue of overtreatment, Campagna reports. Electronic health records have helped, but the industry is still working out the bugs of interoperability. Certain software products do not interface with other brands, so hospital systems are unable to share the patient records. “It’s been very frustrating for all of us,” she says.

However, there have been notable steps toward progress in hospitals, Campagna adds, and case managers are at the heart of that progress. “Communication has been key. In interacting with the physician, patient, social worker, and therapists, case managers facilitate that communication.”

One primary example: Case managers have had an integral role in working with the utilization review process, and this has helped rein in the excess, says nurse advocate Anne Llewellyn, MS, BHSA, RN-BC, CCM, CRRN.

Utilization Review Helps

Each hospital’s utilization review (UR) department is separate from nursing. UR receives day-to-day reports of the patient’s progress and shares this status report with the insurance company for approval and precertification of scans, tests, and treatments, even the hospitalization itself.

During this UR process, the case manager acts as intermediary with the multidisciplinary team in working out details of the treatment plan, Llewellyn explains.

“Case managers work with physicians to inform them about the patient’s progress,” she says. “From that interaction, the team can implement the plan in the most effective, efficient, and timely manner to meet the patient’s needs, [and to] ensure the plan is working and meets evidence-based guidelines. When these things line up, it ensures the plan is cost-effective.”

“The case manager plays an essential and multifaceted role by supporting the patient as they transition throughout their hospital stay,” says Dana Deravin Carr, RNC, CCM, DrPH, MPH, MS, care manager for high-risk transitions initiative at Jacobi Medical Center in New York City.

As patient advocates, care managers coordinate and support the patient-centered care delivery process. Working in collaboration with the physician-led interdisciplinary team, case managers conduct ongoing assessments of the patient’s clinical status, clarify and monitor medical interventions and associated treatment, and evaluate clinical outcomes — all of which enhance patient safety.

By working collegially and collaboratively with their interdisciplinary peers, case managers assume the vital role of ensuring that patient-centered care delivery is appropriate, timely, and medically necessary, thus minimizing the occurrence of overtreatment, Carr explains.

Utilization review is helpful, but without a informed comprehensive assessment and care coordination by the case manager, it will not reduce overutilization, Campagna says. Communication and coordination are critical.

The case manager also can educate patients who request extra tests to confirm results, adds Campagna. “If validity of the first test is high-caliber, why have unnecessary tests that may be expensive and uncomfortable for the patient? Why can’t we trust the results of the primary test?”

The focus is on streamlining the process so patients get what they need when they need it, from the right provider, she explains. “Could they benefit from seeing a specialist or another service provider like occupational therapy or physical therapy? If you provide the right service, you get them to recovery quicker.”

Elderly patients are particularly vulnerable to overtreatment, Campagna adds. They may not hear or understand what the doctor says, or it may be too technical.

Focus on Education, Understanding

“One thing the case manager can do when dealing with an elderly patient is to encourage at all times that they have a care partner with them,” she explains. “The elderly person may not hear or fully understand what a doctor says, or they may be afraid to ask questions.” Having a family member or friend with them allows another set of ears who can listen, take in information, and understand the plan of care.

That is where a care partner can help, Campagna says. Typically, the care partner is a family member, but a neighbor or friend is fine. Or, the hospital team can recommend an independent case manager to act as the patient’s care partner/advocate, keeping long-distance family members apprised.

The care partner accompanies the patient in all health-related discussions, asking questions and recording responses. “When they leave the office, they have something tangible, they have notes — what was said and options that were presented,” Campagna explains.

A case manager also can help patients understand their options, both the risks and benefits. How much mobility do they expect from a hip replacement? Do they want to work in the garden, get up the stairs in the house, or run a marathon? The case manager helps patients think about the outcomes they want so they understand the limitations of the procedure.

“Just because the procedure is an option doesn’t mean it’s effective in every case,” says Campagna. “The case manager can help the patient understand the options realistically and make informed choices.”

Transition from hospital to home is another critical juncture. “We do very well with hospital case management and setting up services at the home, making sure we have all of the necessary insurance approvals,” Campagna says. “But 24 hours later, if the home care service hasn’t arrived, the patient goes into a panic. They don’t understand what is happening, who to turn to.”

Case managers can easily circumvent that panic by giving the patient a number to call if he or she has questions. Also, they can reassure the patient with education about what to expect following the treatment or procedure.

Be sure to repeat patient discharge instructions multiple times, Campagna adds. Patients do not always remember the instructions they were given for self-care, or may misunderstand what they hear. Too often, that results in readmission.

“We need to prepare patients before they leave the hospital,” she explains. “We need to repeat instructions and ask them to teach back what they’ve heard to ensure they understand. Then, we need to send them home with written instructions so they can share them with caregivers, so they understand, too.”

For many patients, there also is need for education on lifestyle changes, adds Llewelyn. “We can’t have them going to McDonald’s instead of a balanced diet. We can’t discharge them with all new medications if they have no money to buy the meds. We’ve got to ask questions and educate our patients on managing their condition appropriately so we reduce setbacks or complications.”

If the patient needs help making lifestyle changes, the case manager must help that patient find what will motivate him or her to achieve better health. It is known as motivational interviewing, or “meeting the patient where they are,” she explains.

For example, a heart failure patient may work toward attending a daughter’s wedding as their motivator for weight loss. Or the case manager can develop an exercise and diet plan to help the patient lose a little weight so she can get into a nice dress. That motivation will help the patient reach her goal — and that helps the healthcare team reach the goal of helping the patient follow the plan to avoid a readmission.

Patient engagement is key, Llewelyn explains. “The patient has to do the work, they have to make the right choices. Or they can decide they don’t want care. They’ve been battling this their entire lives, and they may choose to stop care and let natural events occur. We have to remember, patients have choices, but they need to be informed about their choices and the impact of those choices. Case managers work with each patient so they make the right choices for them.”

Without patient and family engagement, readmissions will continue — another form of overtreatment. “We’re getting patients out the door faster than before, but are we educating them? No, because we say we don’t have the time,” says Llewelyn. “So, it becomes a revolving door. We know how to fix that problem. It’s in patient education.”

Patient education should begin as early in the admission process as possible, adds Carr. “Patients are often overwhelmed and can only digest small bits of information at one time.”

Referrals for skilled home care services and early physician follow-up are crucial to ensuring patient understanding and adherence to these very important care interventions, she says.