In August 2020, we lost Karen Zander, one of the true pioneers in hospital case management. Karen’s name is synonymous with acute care case management. She spent a large part of her professional career advancing case management roles, models, and the measurement of case management outcomes. Karen was a contemporary of mine. My introduction to case management came in 1988, hers in 1985. That may not seem that long ago, but 1985 started the clock for case management in its movement from the community into hospitals. Karen is one of the main people who wound the clock. It is no surprise that her passing has made me think a lot about those early days and the difficulties she, and many of us, experienced. I believe that to understand where we are going, we need to understand where we have been. I would like to share the journey that brought us to this place in time in case management.

In 1985, the Centers for Medicare & Medicaid Services (CMS) introduced prospective payment and diagnosis-related groups (DRGs) to healthcare as a new reimbursement scheme for managing cost and length of stay. Before, there was no process for controlling either cost or length of stay. In fact, hospitals received more reimbursement if they used more resources on a patient and kept the patient in the hospital for longer periods. This was not meant to cheat the system. It was true in the 1980s that the use and availability of post-acute care were limited. It was general practice to allow patients to fully recover before they were discharged from the hospital. The bright light of healthcare shined on the hospital. Care began and ended there.

This was all well and good, but hospital care is expensive, and costs continued to rise. In addition, patients developed complications or experienced errors and falls while they were in the hospital for protracted periods. The thought of shortening length of stay required an entire paradigm shift for hospitals and healthcare systems.

Then came case management. Long known as a community model in psychiatry and social work, the questions were simple: Could the principles of case management be applied to the acute care setting? Would it work? What would it look like?

When it is said that part of a person’s success is being in the right place at the right time, I think this is true for Karen. She was working at New England Medical Center (NEMC) in Boston. NEMC wanted to try a new model to manage costs and length of stay, deciding a nurse-driven approach would be best. The model was called the Primary Nurse Case Management Model. This early model was based on the concepts of managed care. This managed care was outcome-oriented, patient-based, set in a particular time frame, and focused on the appropriate use of resources for both inpatients and outpatients. The case managers, who primarily were registered nurses, also provided direct patient care while the patients were on their units. Once the patient was transferred, the case managers coordinated the care of these patients throughout the stay, regardless of the unit. Care was coordinated through collaborative group practice arrangements, using DRGs to identify the appropriate length of stay and critical pathways.

In hindsight, we can see the many flaws with this model. Despite these flaws, this was one of the first strategies a hospital used to manage costs and lengths of stay using RNs. It opened the door for many revisions and adaptations over the years as healthcare reimbursement changed, costs continued to rise, and lengths of stay shortened.

The original concept of direct patient care integrated with care coordination did not include some of the roles we consider fundamental to today’s models. In fact, Karen added these roles, evolving her model over time. She started with what we think of today as a “purest” model, one in which RNs are clinically focused and not involved with the business side of healthcare. Discharge planning remained with social workers. Eventually, she added utilization review and discharge planning, and removed direct patient care. This transition was critical in the integration of roles that had been disconnected from each other. This disconnect had added to costs and lengths of stay.

As with any pioneer, Karen’s success was in experimenting and revising as more information was gathered and outcomes were measured.

Critical Pathways

Karen pioneered critical pathways. These tools were adapted from engineering pathways developed to outline the critical, activities needed to complete a project within certain time frames. A delay in one task could potentially delay the entire project. Each team member’s responsibilities in the completion of these tasks is clearly demarcated.

A simple example of building a house can explain the concept. First, cement makers must pour the foundation Then, carpenters must erect the frame. The electrician must wire the house, and the plumber must install the pipes and fixtures. Each activity must be completed within a certain time frame so as not to slow down the next worker in the process. It is simple but describes the logic of critical pathways.

Unfortunately, engineering and healthcare delivery have some fundamental differences. Patients bring a lot of variation, as do physicians and ancillary departments. It is difficult to stay on a straight path without deviation every day. Because of the variation in managing clinical care processes, the need to understand variation from the critical pathways became important. Monitoring variation became the next need in the process. Variances identified delays in care progression and fell into multiple categories that were like avoidable delays today, and became strategically linked to the critical pathways.

The table at the bottom of the page is an early example of a critical pathway for uncomplicated myocardial infarction (MI). Please note the length of stay is much longer than today, and care progression is much slower. The first four days are included, but the expected length of stay is eight days. Because the case manager also was the bedside nurse, there is a lot of focus on nursing interventions and outcomes. This would evolve into multidisciplinary interventions and outcomes as the tool matured.

Note the excessive use of resources on an uncomplicated MI patient, including such interventions as cardiac rehab, a cardiac cath on day 3, and so on. It is interesting to see how things have improved over the last 30 years. Also note the discharge planning process — quite slow and performed twice a week.

Imagine trying to follow a tool like this on paper and without a computer, telling doctors they had to shorten lengths of stay and use fewer resources. Try tracking, collating, and analyzing variances on paper. I actually did all these things. It was time-consuming and minimally productive. In fact, at times, it felt like pushing a boulder uphill. Managed care was not prolific, and doctors believed any controls over resource use was an invasion of the physician/client relationship. They did not want their orders questioned, and made that quite clear. It took many years before the notion of managing length of stay and cost of care would take hold and become part of the daily vernacular in healthcare.

Part of that change in the physician practice patterns was attributed to the managed care penetration that took off in the early 1990s. This was the first time physicians were truly responsible for their resource consumption, as managed care organizations added a new layer of review to the requirement that patients meet medical necessity every day, and that cost of care was controlled.

It was around 1988, the time of the early critical pathways, that I met Karen. By then, she was known in the case management arena for her early work on critical pathways and was sought for her expertise. Many of us focused more on the pathways Karen developed than the case management model she had implemented at NEMC. They seemed like an excellent tool for those early acute care case management programs that were popping up across the country.

At that time, I was hired to direct a research study in New York City. The United Hospital Fund, a philanthropic organization, awarded five hospitals with grants to try new care delivery models. How forward-thinking they were. They were seeking innovative models to control costs and lengths of stay, as well as improve patient and provider satisfaction. I became the project lead for the study at the Long Island Jewish Medical Center (now part of Northwell Health). Working under the vice president of nursing, we developed a model we thought might work to achieve these goals. This model did not use bedside nurses, but created a new role that we called the case manager. They managed the clinical care processes, but did not work on discharge planning or utilization review. I read everything I could about these topics and found Karen’s work as well as the work at Carondelet St. Mary’s Hospital in Tucson. As far as I am concerned, these nursing-led initiatives were the two case management models producing the most groundbreaking work at the time. Neither model is recognizable today.

I asked Karen to come to Long Island Jewish and present her critical pathways to our team of physicians, nurses, and administrators. We launched our new model on seven pilot units, and outcomes already were happening. Could the critical pathways bring us even further? Karen spent several hours explaining her work to the team. Even the physicians were intrigued by these novel ideas. I bought several of her early pathways, and we were off and running. As the grant proceeded, we adapted and modified them to our team’s liking.

Changing Times

I remember feeling amazed with Karen’s forward-thinking approach and her ability to make sense of it. The late 1980s and early 1990s were an exciting time in case management. Karen left NEMC and started her own consulting company. Her experiences as a consultant helped shape and form newer case management models.

While I stayed in the acute care setting and moved up from director to vice president to senior vice president, I also began refining and testing these early models. It was clear these methods worked, but it was hard to convince senior executives. Implementing these models required additional personnel. New departments had to be formed, and budgets created. A return on investment usually was necessary to convince leadership that case management was an intervention that could positively affect their bottom line in terms of quality and financial outcomes.

Right now, readers might be thinking not much has changed. In some ways, this is true. The struggle continued for a long time, and continues today in some organizations. Case management has been slow to standardize models, staffing ratios, and outcomes. This has added to the confusion as to its effectiveness and value. The introduction of bundled payments and other advanced payment models has helped bring case management into the limelight, but it remains a struggle. Community-based models are starting to emerge, but we are not quite there yet.

Looking Forward

Among the many struggles we still face, some good things have emerged. Many organizations have embraced case management, and some even staff their departments appropriately. Case managers are highly trained and can contribute to positive outcomes for their departments and their organizations. These positive trends help me feel proud of the work that Karen, I, and other early pioneers did and continue to do. In my own case management journey, I have been fortunate to meet professionals from Alaska to Florida, from California to Massachusetts. I have even traveled to South America, Europe, and Asia, bringing these ideas and concepts to other countries trying to implement similar programs.

The field of case management will miss Karen. So many of us will remember her fondly. Her spirit, her humor, and her apparent joy in her work always was obvious and will not be forgotten.

Critical Pathway for Uncomplicated Myocardial Infarction


Day 1: ED

Day 2: CCU

Day 3

Day 4: Transfer
to Medical Floor

Consults



Cardiac rehab PT and OT

Tests

CBC

ECG

Electrolytes

Cardiac enzymes

Glucose

BUN & creatinine

Chest X-ray

CCU

Assess enzymes

Chem profile

ECG

Electrolytes in a.m.


Activity

Bed rest

Bedrest with commode PRN

Up in chair
and progress

Progression of
self-care ADLs

Treatments

IV KVO

Vital signs q 15 min

Daily weights

Input and output

VS q 4h and PRN

Heparin lock

VS q 8h

Medications

Nitrates,

O2 2-4 L

Analgesics

Lidocaine

Stool softener

Beta-blockers

Calcium channel blockers

O2 PRN

Diet


Low cholesterol


Discharge Planning

Begin ED evaluation

Complete intake
assessment

Assess home environment

Mutual goal setting

IP and OP plans
of care

Multidisciplinary staffing twice a week

Inpatient cardiac rehab


Key Nursing
Interventions

Orientation

Assess and monitor

Patient education

Orientation

Assess pain

Position for comfort

Assess and monitor

Position for comfort

Patient booklet given

Orientation to TV channels

Medication instructions

Risk factor instructions

Assess patient readiness to learn

Instruct on goal setting

Stress management

Key Outcomes

Patient verbalizes pain; fears and anxiety; reason for hospitalization

Patient demonstrates use of call light

Patient’s behavior indicates pain reduction

Patient verbalizes feeling less pain

Patient verbalizes understanding of
diagnosis

Patient voices
concerns, if any

Patient watches
educational TV

Patient behavior shows progress toward acceptance of diagnosis

Patient identifies learning needs

Patient verbalizes own risk factors

CBC: complete blood count; CCU: critical care unit; IP: inpatient; KVO: keep vein open; OT: occupational therapy; OP: outpatient; PT: physical therapy