Balance clinical, financial sides of patient care

CM, UM should go hand in hand

Case managers are in an excellent position to help their hospitals balance both the clinical and the financial sides of patient care, asserts Teresa C. Fugate, RN, BBA, CPHQ, CCM.

"Health care is in a bad way and can only get worse if we don't start running it as a business, looking at the services we provide, what reimbursement we get, and trying to streamline processes," explains Fugate, manager at Pershing, Yoakley & Associates, a Knoxville, TN-based health care consulting firm.

Clinical people usually don't understand that everything they do in a hospital determines the revenue that the hospital is going to bring in for that year. Unless clinicians are trained in the financial aspect of their organization, they won't see it as a priority, she adds.

If a hospital has separate departments for social work, utilization management, and case management, they all should work as a team to coordinate care, Fugate says. 

"But even when the case manager is doing all of it, I still see the breakdown. The individual may lean toward either clinical or financial rather than pulling them together," she adds.

The case manager needs to look at psychosocial issues, deal with the clinical issues, make the necessary phone calls to payers, and work with the physicians so the hospital will be reimbursed, she adds.

When Fugate consults with hospitals, nurses and nurse case managers sometimes tell her they went into nursing to take care of patients, not to deal with whether the hospital brings in revenue.

"That's a noble cause, but if nurses want to keep their job and want a nice facility with the newest and best equipment, they have to be in tune with what they do in the organization and how it affects the revenue produced by the organization," Fugate notes.

That's where case managers can come in.

Case managers are in a prime position to help nursing understand the financial side and to help the financial side understand the clinical side and how not being paid affects the clinical components, she explains.

That's not the case in many hospitals, Fugate adds.

In some hospitals, case managers focus primarily on clinical activities. In others, their major role is utilization management and they don't deal much with clinical issues.

Fugate is quick to add that she never advocates for one particular kind of case management model, but whatever the model, she recommends that case managers balance the clinical and the financial.

"We are in the business of health care. We want to take care of the patients, but we can't take care of them if there is no money coming in," she adds.

Here's an example of how to have a clinical and financial focus:

One common hospital model is to have separate departments for case management, utilization review, and social work. These departments often are in individual silos and don't communicate much, Fugate says.

"There is no overall plan of care for the patient and no streamlining of communication between the three," she adds.

Fugate recommends that the three departments work as a team and communicate on a daily basis what is going on with each patient. She suggests that the case manager is in a good position to coordinate the communication efforts. If a hospital has such a model, Fugate recommends that all members of the team be cross-trained so they understand what each is trying to do.

For instance, if a patient has more social work issues, the social worker will be spending a lot of time on social issues that are impeding recovery or discharge.

At the same time, he or she has to understand the utilization piece and the clinical piece in order to assist with those issues as well.

The team should sit down every morning and discuss each patient. For instance, the utilization manager may say one patient's insurer will pay for only two more days.

The social worker becomes aware of insurance constraints and can make sure the patient's social needs are taken care of so the patient can be safely discharged. The case manager knows he or she has to work with the physicians to make sure the clinical issues are covered.

Team members should shadow each other

"If the team doesn't communicate, the social worker could believe that he or she has another week to work with the patient's social issues, and the clinicians may not realize that some clinical issues have to be taken care of," she says.

Fugate suggests that the team members follow each other around for a week to get an idea of what goes on in each department.

"The case manager works with the social worker and makes sure she is learning about clinical issues. The social worker makes sure the case manager can identify psychosocial issues, and so on. Even when the case management model calls for the case manager to do everything, the model often tends to lean toward either the clinical or the financial rather than pulling all three together," she says. "It's a juggling act, but there is a way to handle it."

Hospitals that do not operate efficiently and haven't streamlined their operations have higher costs. If the staff don't follow standards of practice, there is going to be a lot of variation in care, which can lead to medical errors, she adds.

"The case management plan should be looking at the clinical component and the financial component. Usually, you have to address the clinical issues to meet the financial issues. If you are overusing resources, you're not going to have a good bottom line," she says.

Case managers in the hospital setting can use their knowledge as a powerful tool to help the organization streamline processes and improve quality of care, which in turn improves reimbursement, she says.

"One of the things we've found as we work with hospitals is that a lot of time there is a misalignment of priority from the hospital leadership down to the case managers. The case managers are doing the job they believe they should be doing. The administration says it's not getting the results it needs," she says.

The case management program should be built on the strategic plan of the organization.

For example, if the strategic plan is to reduce the length of stay for the top 10 diagnosis-related groups, the case management department should hold its own strategic planning session and identify its top five priorities for the next year based on the organization's strategic plan.