By Jeni Miller
Approaching one year after COVID-19 began spreading in the United States, case managers are considering how to make the most of their new perspective in 2021 and beyond. The pandemic has shone a light on case management program and healthcare facility weaknesses, but also has brought new opportunities for leadership and advocacy. What can case managers do to maximize these opportunities and avoid pitfalls?
“I know I learned a lot about this at ground zero on 9/11,” says Toni Cesta, PhD, RN, FAAN, partner and consultant at Case Management Concepts in North Bellmore, NY. “When so many hospitals are having capacity issues, you have to constantly reprioritize how you might want to do things differently.”
It takes the whole team to make it happen, Cesta says. “I think you have to look at your staffing every single morning and up-staff or down-staff as you need to, depending on where you’ve got overcapacity issues or bottlenecks.”
This reassessment can make a difference when there are many discharges planned in a day, or to ensure there is enough case management staff in the emergency department (ED). “You need regular, comprehensive assessments to deploy staff to where they’re most needed,” Cesta explains. This is the biggest challenge right now, but once the leader has deployed staff in the morning, don’t stop there. Keep assessing throughout the day.”
As uncomfortable as it can be, reprioritizing day by day and, as Cesta calls it, “turning things on their heads to really focus on today’s issue,” can help the staff become more proactive.
“We should all expect that between COVID, hurricanes, floods, and everything else, any hospital in any part of the country can be impacted by capacity issues,” Cesta shares. “You never know what kind of emergency might happen, so being proactive and always being prepared, the whole hospital, that’s key.”
Maintain the Flow
When those capacity issues hit, like they did in many places throughout 2020, it is important to know when to reorganize the four main case management roles to concentrate on patient flow and capacity management.
During a pandemic, be sure to “prioritize the work in this way: patient flow, capacity management, discharge planning, utilization management,” says Beverly Cunningham, RN, MS, partner and consultant at Case Management Concepts. To make this happen, says Cunningham, consider these tactics:
- Keep the patients moving;
- Conduct quick, daily rounds;
- Know the day’s discharges;
- Order transportation the day before so there are no delays;
- Make sure families know when the patient will be ready to go at least a day ahead if you can.
“Usually, patient flow would not be No. 1, but during a critical time, things like reimbursement are less of a priority while the biggest thing is opening beds for sick patients,” Cesta explains. “Expediting the process should be at the front and center of the day as a case manager, making sure that discharges are happening in a timely manner, that treatments and procedures are timely, and that people are not staying in the ED longer than they need to if they’re known to be moving to an inpatient bed.”
During a high-capacity period, Cesta and Cunningham recommend that staff abbreviate patient rounds. “But don’t eliminate them — these rounds are necessary also for knowing when beds will free up,” Cesta adds.
Utilization review and discharge planning should be closely aligned and especially aggressive during times of high capacity, or generally during a pandemic or disaster.
“It’s all about movement of the patient,” Cesta explains. “The minute a patient can be discharged from an ICU, make that happen. Focus on really aggressive utilization reviews so a patient can move to a lower level of care as early as possible. We do this every day anyway, but make this a very aggressive process throughout the whole day. During a critical period, work closely together and prioritize the work unit by unit, and even hour by hour.”
She also recommends case managers look closely at any potential delays. Many of these can be avoided by keeping an eye on the following, which account for the corresponding percentage of unnecessary extra days:
- Unnecessary admissions: 15-20%;
- Test/treatment delays: 20%;
- Lack of home care arrangements, nursing home beds, and more: 10-15%;
- Physician practice/custom: 50%.
There are several ways to plan and prepare for an influx of patients. It is important to consider how to optimize each facility’s space.
“Some hospitals have found success in creating a ‘discharge lounge’ when at capacity,” Cesta says. “This frees up a room by providing a lounge area where the discharged patient can go while they wait for their family.”
Others make use of swing beds, using existing beds in a different way by repurposing recovery rooms or rehab rooms as COVID-19 units. Another option is to temporarily halt elective surgeries.
“Using a grid of some sort can help case managers be proactive and have a plan identifying potential problem areas and managing high-capacity situations,” Cesta says. Leadership and staff should consider following this pattern:
- Each morning, review how many patients are in the ED.
- Review ED volume against expected discharges to determine capacity issues.
- Understand where bottlenecks may happen based on bed needs.
- Use a grid to help identify potential problem areas.
- Build these into your patient flow software, if possible.
During critical times like the COVID-19 pandemic, emergency declaration blanket waivers can help enhance patient flow and ease the decision-making process for leadership and staff.
“Case managers should be acutely aware of these waivers because they’re designed to help them move patients more quickly,” Cesta explains. “For example, discharge planning waivers allow for high COVID capacity hospitals to avoid using a choice list. The three-day skilled nursing facility rule is also waived, as well as EMTALA [Emergency Medical Treatment and Labor Act], among others.”
If case managers can use these waivers, they can move patients through the care continuum more quickly and help more people as needed.
Build New Bridges
Developing new and better relationships with other healthcare partners also has proven critical in 2020. This can make the difference between hospitals that thrive and those that barely survive. For instance, building partnerships with home care agencies can help case managers and leadership prepare for times of high capacity.
“I think home care has really stepped up and realized how significant the capacity issues have been this year,” Cesta says. “If you have those dynamic relationships with home care or sub-acute facilities, that will really help everyone. During a time like this, if you’re regularly conversing with them and explaining current issues, these agencies may even be able to help the same day.”
Hospitals that are “newly COVID-intense,” according to Cesta, “may not have been thinking about those providers.” She recommends any hospitals that are not at capacity should be “thinking about and developing relationships right away” so they are prepared if COVID-19 intensifies in their area.
“To avoid an unnecessary hospital admission, try to work closely with home care agencies,” she adds. During high-capacity periods, one trick of the trade is to ask a home care agency representative to sit in the ED alongside patient intake, as their joint assessment might shorten turnaround time by four to six hours.
Working closely with post-acute, home care, and skilled nursing facilities can be critical to capacity management, and can even result in a positive working relationship to carry into the future.
“In 2021 and beyond — regarding capacity issues, for one — people will be rethinking what they can do with overflow,” Cesta notes. “Having considered where they might get beds and equipment, where they could put an overflow of patients, and even how they’ll access staff, if needed, knowing their options and having processes in place will benefit them in the future. That’s another positive that has come out of this.”