By Jeni Miller
Whether for financial reasons, to improve integration of care, decrease duplication of clinical services, or to mitigate the financial effect of COVID-19, more hospitals are choosing to consolidate into larger systems. What can hospital case managers do to prepare for this, and how can they handle the transition with grace?
According to Jean Maslan, RN, MHA, ACM, CCTM, senior consultant of The Center for Case Management, several processes may change as standardization takes place across the system.
“When there is consolidation of hospitals, there may be different EMRs [electronic medical records], and if they elect to go with just one, that would be a change in the workflow for the case manager,” explains Maslan. “Eventually, processes would need to be changed to standardize the work across all hospitals. There will be a need to understand the bigger picture related to outcomes; for example, understanding in-network vs. out-of-network.”
As consolidation begins, “a thorough assessment should be done at all the hospitals to identify leading best practices among the hospitals, which should then be implemented systemwide,” Maslan says. “Standardization and accountability are the key.”
Patrice Miller, MSN, MBA, enterprise vice president for care management at Jefferson Health in Philadelphia, agrees. Miller was instrumental in the success of the consolidation of four hospital campuses into Jefferson Health.
“It was a conscious decision to centralize the utilization review processes, and we needed to pull everyone together into the same workflow perspective,” she shares. “We worked hard to have one consistent message with the staff. We brought them together, discussed how this would impact them, and were very transparent, open, and honest. When we revised policies and procedures and competencies, we did all of that with the staff.”
Maslan adds “communication and education to staff is imperative to help them realize what additional resources are available with a consolidation. For example, patient transfers between the hospitals would be important. Creating transfer agreements amongst the hospitals to send patients back to the sister hospital for potentially longer discharge planning issues would be a start.”
The Day-to-Day Difference
For anyone experiencing a change in the workplace, questions about what this might look like daily are normal and expected. While “day-to-day operations would not change” says Maslan, “awareness on the case managers’ part will be crucial.”
The most noticeable change for case managers during a consolidation, according to both Maslan and Miller, is the utilization review (UR) process.
“Many hospitals are centralizing the UR process. When several hospitals are consolidating into a big system, it would make sense to centralize this process,” says Maslan. “There is such a negative financial impact when UR is not done accurately. You need efficient and accurate processes. By doing a thorough assessment of the UR function, numerous opportunities can be identified in lost revenue.”
Of course, there are some best practices to keep in mind regarding the centralization of UR.
“By centralizing the UR process, it is important to make sure the lines of communication are kept open between the UR nurse and the case manager,” Maslan explains. “Utilization review should be driving the discharge process. It is key to have a good communication plan in place between UR and case management. By implementing best practices and standardizing processes, you can realize a reduction in denials. Correct patient status right out of the gate will realize revenue as well.”
Maslan also suggests hospitals consider adding clerical and administrative staff to support UR nurses, especially when it comes to duties that do not require an RN license.
“Responding to payer requests is very time-consuming for the case management staff,” she says. “Administrative support staff can retrieve phone messages from payers, fax and send clinicals, enter authorization numbers, and many other tasks. This will free up the nurse to communicate with providers and bedside case managers.”
Leadership and Culture
For those leading the charge and working to help make a consolidation transition successful, it is important to be sensitive of the various workplace cultures that already are embedded in the life of each hospital.
“There are definitely different cultures at each division, and you really need to take into consideration those different hospital cultures,” explains Miller. “The mindset of the leadership can help shape the understanding of the enterprise concept and affects how everyone works together to create consistency and to standardize across the enterprise.”
Maslan reiterates the importance of leadership for setting the tone for success. “A strong leader of the case management program will be imperative to assist in identifying leading best practices and implementing changes across all hospitals. It is beneficial to have revenue cycle integration with the UR team as well. Hospitals lose millions of dollars from insurance denials and writeoffs. With revenue cycle integration, trends can be identified and rectified. It will be important to develop an exceptionally good communication plan and to be transparent with all members of the team to minimize the potential for duplication of work.”
Case management leadership also would be wise to check in periodically with both stakeholders and staff to continue fine-tuning the consolidation process.
“It would be helpful for leaders from all the hospitals to come together collaboratively on data, such as avoidable day data and denials data, to address and solve trending issues that are common amongst them,” says Maslan. “They can all learn from each other.”
For everyone involved, Miller suggests they endeavor to be “transparent and honest” during the process, and that staff always should “reach out with questions, remember not to dwell on things or make assumptions. The goal is for everyone to be informed, and for it to all work out well.”