By Jeni Miller

Case managers often are pulled in different directions — not just in terms of the many duties with which they are charged, but also with competing goals. Take patient satisfaction vs. hospital spending. Are these two diametrically opposed? Not necessarily, and not always, it seems.

The main hospital spending metric is length of stay — especially during the COVID-19 crisis, says Beverly Cunningham, RN, MS, partner and consultant at Case Management Concepts.

“For some reason, there seems to be an increase in the focus on length of stay,” she says. “Some of it may be due to the financial impact that hospitals are seeing with having to stop elective surgeries and depend, for the most part, on their medical patients for their payment [due to COVID-19].”

Of course, longer length of stay does not only affect spending, but also patients who are waiting in the emergency department (ED) for admission.

“Patients waiting for a bed in the ED have been a challenge for many hospitals,” Cunningham shares. “This was true, to a certain extent, before COVID, but it is definitely higher with COVID. Also, larger hospitals that would accept more complex patients through their transfer center are not able to take these higher-level patients because there are no beds.”

This matters, she adds, because it affects the hospital’s ability “to accept more complex patients with higher reimbursement, and hospitals that traditionally transfer to them could get in the habit of transferring to a hospital that has had more ability to accept their transfers.”

All this pulls on hospital spending, while at the same time potentially causing patient satisfaction to take a nosedive. Patient satisfaction may be harder to come by in crisis situations due to several factors — the most common of which is communication.

“Patient satisfaction has been challenging during the COVID experience, as families are dependent on calls from physicians, case managers, and nursing to help them plan for the next steps for their family member,” Cunningham says.

Communication delays from any of those sources could increase a patient’s length of stay as families take longer to plan for an appropriate post-acute care setting for their loved one. Not only that, but since the case manager’s own communication may look different from the typical bedside visit — taking place instead by phone, FaceTime, or Zoom — it may be more challenging for the patient to be sufficiently involved in his or her own discharge plan. Cunningham explains that even patients who are not hospitalized due to COVID, but rather another reason, may not be seen in person by an RN case manager or social work case manager. This is a great concern, too, because communication is one of the most critical questions on the patient satisfaction survey.

An Impossible Goal?

In some ways, it seems that it is nearly impossible to please both the hospital administration and the patients and their families, especially in times of crisis. However, the case manager is in a unique position to bring both along — assuming they have the right tools to do so. Without the help of a wise and invested hospital case manager, the chances of a positive experience for the patient are lower, and hospital spending is more likely to be higher.

“Depending on the orientation process for the case manager, whether it is an RN case manager or a social work case manager, the leadership mentoring and support of case management staff and the sense of urgency by the entire discharge planning team, the odds are out there,” Cunningham says. “If a case manager does not understand the need for a sense of urgency in discharge planning and care coordination during the hospital stay, length of stay may be impacted negatively.”

Since communication is so key, especially when face-to-face interaction is limited, it is even more important for case managers to find ways to prioritize it. That also can help the hospital achieve its spending goals.

“Case management staff who delay returning phone calls to families and/or patients can also [extend] length of stay and/or [harm] patient satisfaction,” Cunningham explains. “Working with a goal of prompt and complete communication with patients and/or families, as well as a sense of urgency in the care coordination and discharge planning processes, will result in a huge step to achieve both patient satisfaction and hospital spending.”

Cunningham suggests several tips for the case manager who wishes to keep an eye on both priorities:

  • Look closer at avoidable days. Tracking, reporting, and intervening in any avoidable days can help identify gaps in shortening length of stay.
  • Set complex cases apart. A complex discharge planner, most often a social work case manager, can focus on the more complex discharge plans, leaving the unit social work case manager to focus on his or her caseload. Patients with complex discharge plans can, at times, take several hours in a case manager’s day, leaving little time to focus on the other patients in his or her work.
  • Assess early and fully. Complete the initial case management assessment on the day of admission with an appropriate and timely referral to a social worker, as needed.
  • Leading and mentoring. Leadership in the case management department means regular rounding, with a focus on mentoring their case management team members. They also should look at their orientation program to ensure it produces best-practice staff.
  • Know patient satisfaction is not just a bonus. With satisfaction a part of value-based reimbursement, the patient experience is important. For example, when a patient is in a hospital that allows one visitor per patient and then transfers to a skilled nursing facility that does not allow visitors, that is a huge dissatisfier for patients. Some patients have even asked to stay in the hospital longer just so they can see their visitor.

It is not a pipe dream to achieve both patient satisfaction and appropriate hospital spending, but it definitely takes intense focus and prioritization to make a healthy bottom line and a healthy, happy patient a reality.