By Melinda Young

EXECUTIVE SUMMARY

One of the first steps to streamline case management operations is to reassign staff to new roles, such as focused discharge planning jobs and utilization review.

Another method is to create a risk assessment tool to assess each patient, and indicate when patients need a referral to a complex care coordinator.

Daily huddles help team members, providing time to discuss potential problems, and to discuss how to shift work within the team to be most effective and efficient for the day’s caseload.

Focusing on social determinants of health allows case managers to help patients with sociobehavioral health issues, as well as other factors underlying patients’ poor health habits.


Hospital case management departments can improve efficiency and streamline their operations by following some tips from The Valley Hospital of Ridgewood, NJ.

Here are the steps the health system took to improve care coordination:

• Reassign staff. “We took home care coordinators into our department,” says Margaret Pogorelec, DNP, RN, CEN, NE-BC, director of care coordination at The Valley Hospital.

They asked case managers whether they preferred discharge planning or utilization review (UR) work, and assigned them to a role. The nurses already performing Medicare UR were trained on UR for commercial payers as well. One nurse and a social worker were assigned to identify patients at risk for a 30-day readmission, and the hospital created a full-time ED case manager position, she says.

A new role is the complex care coordinator, who has a master’s in social work. The coordinators handle high users of hospital and ED services. Their patient load is smaller than those of other case managers — maybe six to nine patients at a time. But their patients might be homeless and suffering multiple chronic conditions, as well as health access issues, Pogorelec explains.

Another new role is the transition care coordinator. These case managers cover two units, 15-20 patients at a time. They provide an additional level of support, including scheduling follow-up visits, and sending patients to the next level of care.

“All of these changes were budget-neutral because we streamlined so much of the workflow, not adding staff — just reorganizing them,” Pogorelec says.

It takes time for the reorganization to work, she notes. When The Valley Hospital first reassigned case management staff according to their preference of either UR or discharge planning, there were too few UR associates.

“We had more people interested in discharge planning than utilization review,” Pogorelec says. “But as people retire, through attrition, we reposted those positions as utilization review and hired from the outside.”

Pogorelec did not want to force people into a role they did not want, so using attrition to help with realigning staff was a better long-term option. It took about six months. The only exception involved a case manager who desired to move into a leadership role. There were no leadership options in discharge planning, so the case manager became a UR leader, Pogorelec says.

• Identify at-risk patients. “We created an algorithm, our modification of a tool by the American Academy of Family Physicians,” she says. “We use it for clinical complexity, and added additional layers for social determinants of health.”

The Valley Risk Assessment Tool assigns each patient a level of complexity from one to nine. (See samples from tool in sidebar in this issue.) Those scoring at a high complexity level are referred to the complex care coordinator, she adds.

There also is an automatic referral to the case management team when a patient has visited the ED five times or more within six months, she says. For example, the ED social worker can step in if a person has ended up in the ED because he or she could not fill prescriptions in the community. The social worker can ensure the prescriptions are filled before the person leaves the ED, she explains.

• Hold daily huddles. The team huddles daily to discuss any potential problems, and how to shift work within the team to be most effective and efficient for the day’s caseload.

“We let everyone know what it looks like in the emergency room. If there is a high census, we talk about how to prioritize case management,” Pogorelec says. “The daily huddle allows for transparency amongst the team, so everyone can prepare for what the day looks like.”

• Focus on social determinants of health. The case management team can focus on the patient issues that usually are overlooked in clinical healthcare settings: social determinants of health.

For instance, many organizations focus on episodes of care, and develop a discharge planning solution that meets the need of that episode, Pogorelec says. This limits the ability to prevent subsequent admissions based on mental health disorders, finances, access to resources, and family support, she says.

“In our model, the complex care coordinator, working with our team members across the continuum, is able to plan for circumstances that exist outside the four walls,” she explains. “For example, if identified in the hospital admission that there may be an unsafe home environment, not only do we mitigate those circumstances as much as we can during the hospitalization, but we work with our team members in home care, population health, and the post-acute setting, in an effort to ensure and follow up on our discharge plan.”

• Collaborate and provide follow-up care. The case management team formed a relationship with the hospital’s population health department, which helps with handoffs. The team also works with home care organizations, nursing facilities, and other providers. “You have to have people in the community to follow the plans you set forth,” Pogorelec says. “There is only so much you can do telephonically, from the hospital side.”

While the hospital does not own skilled nursing facilities (SNFs), the hospital’s population health staff — RNs and physical therapists — work in the SNFs and coordinate warm handoffs. These are post-acute navigators, a role launched in 2016, she explains.

“Patients go in a lot of different directions when they leave, so it’s critical that we have someone touch base with them,” Pogorelec adds.