Ways to Build and Improve a Case Management Department
At some point, a hospital needs to build or improve a case management department. Whether working from the ground up, completely overhauling a program, or simply making slight adjustments, good leadership and strategy is key to a thriving case management program.
At Nemours Children’s Hospital in Delaware, building a case management/care team was a high priority, but it needed to be handled carefully.
“Our team was started after careful consideration of roles, what adding to the care team could bring and what it could cost,” recalls Maryanne Bourque, MS, BSN, RN, CRCR, director of utilization and case management at Nemours. “In persuading senior leaders regarding this build, I ultimately had to rely on collaboration, accountability, and clear communication. Flexibility and the ability to nimbly pivot when hitting roadblocks were the keys to success.”
To begin the process, Bourque made sure everyone in leadership was on board, which meant taking pains to ensure the new case management department would be built in line with the mission and vision of the institution.
“Buy-in from other senior leaders is crucial, as is framing the plan around the mission/vision and core values of our health system,” Bourque explains. “Communication and being willing to abandon some parts of the plan when they aren’t working was necessary and only made the outcome stronger and more effective.”
As the pilot program was underway at Nemours, Bourque brought in Donna DeFilippis, BSN, RN, ACM-RN, lead nurse case manager, utilization/case management for Nemours. Bourque provided the framework for moving forward, supporting DeFilippis’ efforts at building the role in the cardiac center.
DeFilippis put her experience with healthcare payers and case management to work for the new team. She cut the number of denied days from 200 to 43, and increased the rate of overturned denials from 68% to 95%. Cost savings were realized through reimbursed days totaling $1.5 million, decreased number of days in accounts receivables, and a decrease in cost of appeals.
Employing case managers and leaders with unique skill sets when building a department can help the new program achieve a similar strong start. DeFilippis credits the success of the new program not only to those early wins, but to the leadership provided by Bourque and others.
“[Bourque] communicated so well, constantly praising the work that I’d accomplished, but at same time remaining optimistic when things weren’t going the way we wanted or when we experienced barriers,” DeFilippis shares. “This way, we had a straight path to build the program. As we onboarded new case managers, my job was to mentor them.”
Bourque believes her own nursing experience was vital when supporting DeFilippis as they needed to consistently scrutinize the process and make improvements in real time.
“As a nurse, I was taught early to rely on a nursing process of Assessment, Planning, Intervention, Evaluation, which has evolved to Plan-Do-Check-Act,” Bourque explains. “If not continuously evaluating and re-evaluating, the person planning/implementing isn’t considering new or updated information.”
Since some of the new hires were not experienced in case management, DeFilippis set out to help them become familiar with the discharge planning, utilization management, and financial aspects of case management. She found nurses with strong clinical backgrounds in pediatrics with at least five years of experience could learn case management and achieve success.
Every new program will experience roadblocks along the way. Some might face financial challenges, while others may involve staff.
“Fear of change and the unknown from others impacted by these roles was perhaps the biggest challenge,” Bourque says. “Time, patience, and accommodation of input from others were helpful in resolving these issues. Constant communication and reinforcement of the health system’s vision were vital to allaying fears and concerns.”
“It’s true that people do have a hard time with change,” DeFilippis adds. “But it’s worth sticking with it. Now, if you walked around the hospital, everyone would consistently say, ‘I don’t know how we managed without case managers.’”
Bourque and DeFilippis recommend several key elements leaders should keep in mind when creating a new case management program:
- Choose leaders who involve, consider, and listen to the frontline team members;
- Set clear expectations;
- Celebrate the team’s hard work and escalate to more senior leaders;
- Determine the cause of issues while not taking setbacks and challenges personally;
- Contact other hospitals, peers, and immediate and senior leaders for input;
- Place the right people in the right seats at the right points along the build.
Likewise, improving an existing case management department requires open and involved leadership, strong case managers, and the ability to constantly evaluate and adjust.
“Seek feedback on how things are and where others see opportunities and successes to build upon,” Bourque suggests. “I continuously seek input from other leaders within the field of pediatrics and our organization — senior leaders and frontline case managers alike. I also look to promote successes within the department and the health system so that others not only know what our team does, but [know] how so many issues around care, financial integrity, and health outcomes are influenced by this talented group of case managers. Recruiting newer staff is something we try to keep in line of sight, too, as our team has grown so much. They are the best advertisement for this very challenging, rewarding, and ever-changing career.”
DeFilippis agrees with the importance of strong leadership who offers helpful feedback. She also suggests weekly meetings to discuss the discharge process, working with a chief medical officer or physician mentor when possible, and regularly talking through any current or potential barriers with the team. Still, she says, the success of the case management department will come down to the people, both those who are chosen to work on the front line every day and those tasked with serving on the leadership team.
“As you’re recruiting new staff, you have to be able to pick the right people to fit into your team,” DeFilippis explains. “From my perspective, having leaders supporting you is huge, and Nemours is successful because of the great leaders who guided me throughout this entire process.”
When asked what a successful case management department looks like, Bourque describes it as “one in which the team exhibits interdependence within the team, with other disciplines, colleagues, community resources, and other facilities/hospitals/institutions.”
Bourque recommends all programs should focus on continuous improvement and continuing education to “keep current on best, evidence-based practices.”At some point, a hospital needs to build or improve a case management department. Whether working from the ground up, completely overhauling a program, or simply making slight adjustments, good leadership and strategy is key to a thriving case management program.
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