Inpatient case managers handle discharges, review

Hospital shifts from reactive to proactive focus

When Jeanne Musolf, MS, RN, CCM, talks with new employees about the inpatient case management program at Children’s Hospital of Wisconsin, she often tells them, "expect that how things are currently will not be how they are six months from now. We’re always trying to improve and change."

Since Musolf assumed the role of manager of care coordination services at the Milwaukee facility in April 2001, the department has undergone a comprehensive redesign. At that time, there was a small staff of discharge planners and a separate utilization management department that did concurrent/retroactive reviews and denials.

"The discharge planners practiced in a reactive mode. They responded to orders for home health care or durable medical equipment [DME] as the beginning point for the discharge planning process," she says.

The inpatient case management department took over concurrent utilization review in June 2001. At the same time, discharge planning became more proactive via a unit-based model.

"We went from being a reactive discharge planning department that waited for referrals to come to us to being a proactive case management department," Musolf says.

The hospital now is in the process of shifting all utilization functions to the inpatient case management department. The department now handles concurrent reviews, but retroactive reviews and denials will be added soon.

Department staff were increased so that now a case manager is assigned to each unit in the hospital to handle discharge planning and concurrent review. "We adopted the unit model rather than a population-based model because there are so many children who don’t fit into a particular population. If we assign them by diagnosis, we could have some children who fall through the cracks," Musolf says.

Each nursing unit runs from 24 to 36 beds, except for peak census times in the winter months, when many children are hospitalized for respiratory disorders and the census on some units can climb to 40 or more.

The department has 8.8 full- and part-time employees who cover seven units, including the general medical unit, neonatal intensive care unit, pediatric intensive care unit, surgery/rehabilitation floor, oncology/transplant, intermediate intensive care unit, and a unit that cares for children from birth to 18 months old. Included in that number is the supervisor of the department, Jennifer Friess, RN, CCM.

"The inpatient case managers on each unit have become real experts in coordinating the care for children with those particular diagnoses and issues," she says.

The case manager assigned to a unit reviews the needs of the patients and the payer requests for information first thing in the morning, and then starts the process," Musolf says.

The inpatient case managers at Children’s Hospital of Wisconsin work with all children on their unit but typically spend a great deal of time with the children who have very complex medical needs. Many children go home with gastrostomy tubes/feedings, intravenous medications, and/or on ventilators. Their families need to take care of a chronically ill, medically complex child day in and day out. Complicating the situation is that sometimes the family also has complex psychosocial issues, Musolf says.

Medically complex children must be cared for in their homes or in a foster home because there are no special facilities for them in Wisconsin, she says.

"There are a lot of differences in the pediatric and adult world. With adults, case managers have clinical pathways and disease management programs as resources. We deal with many children who always will be a variance on a pathway," says Musolf.

Handling discharge needs for complex patients who are in the hospital a short time presents a challenge to case managers.

The case managers who work with children in the neonatal intensive care unit, the intermediate intensive care unit, or the oncology unit may have a week or more to assist in transitioning the young patients back to the community. These children require more intensive discharge planning interventions than a child who is in and out of the hospital very quickly, she says.

One of the biggest obstacles to discharge planning for medically complex children is finding a private duty nurse to help with the child’s needs at home, she adds.

"The nursing shortage in the community makes it really difficult to set the kids up with private duty nurses," Musolf says.

Recently, the hospital created a web site for private-duty nurses. These are independent nurse providers who bill directly to Wisconsin Medicaid. The web site offers a way for the hospital to inform the nurses about children who need care, and for the nurses to let the hospital know when they are available.

The inpatient case managers take turns being on call for the hospital’s ambulatory clinics. The case manager on call is paged when an issue arises in the clinics, such as a patient needing home nursing care or DME.

The hospital’s peak census occurs each year from mid-January to mid-April when children tend to have more respiratory infections, making it necessary to add staff on a temporary basis. During peak census, all hospital staff, including the inpatient case managers, sign up to work more hours to accommodate the needs of all the children hospitalized. Children’s Hospital of Wisconsin has had a proactive plan in place for the past five years.

The inpatient case management department has put together a peak census plan that requires part-time people to work extra shifts when a full-time person has a day off or when they are available to be an "extra" (due to high census and demand) during the week. Full-time staff are asked to be on call as a second inpatient case manager on Saturdays.

Musolf has high praise for her case management staff, who always are willing to fill in when needed. "Our staff are unbelievably dedicated. They work as a team. We’ve all had a lot of personal family issues with sick parents or children, and everybody is always willing to come in when they’re needed," she says.

Inpatient case managers rotate covering the weekends. The unit case managers leave messages alerting the weekend case manager of what may need to be done for their patients.

"The inpatient case manager covering the weekend sees the new patients and those who are being discharged. It can be a busy job," says Musolf.

The department also has employees who are designated as float staff and casual staff. The float staff are part-timers who fill in when regular case managers are scheduled off, working weekends, on vacation, or to cover illness. The casual staff are nurses who help out when there is extra utilization management work that needs to be accomplished.

"My vision is to create a case manager associate role, similar to a nursing assistant role. These staff members would team up with the case managers and take on the more technical tasks, such as ordering nebulizers, verifying benefits, or performing simple utilization management activities. That would free up the nurse case manager to become more involved in care coordination," she says.

While the unit caseloads are higher than Musolf would like, she and Friess are working to come up with ways to assure that the role of the inpatient care manager evolves to best accomplish the goals of the children and families who need their services.

"For this kind of model, when case managers perform discharge planning and utilization management, a unit with approximately 20 beds would be ideal," she says.

The department continually is looking at ways to improve the role of the inpatient case manager, keeping in mind the needs of the family, the health care team, and the payers, Friess points out.

"The three components of the role: Care coordination, discharge planning, and utilization management is what the inpatient case manager role consists of and is what the staff strive for," she explains.

"We have a wonderful team of inpatient case managers who have been put to the challenge. They have done a great job on each of their units introducing the role of the inpatient case manager and becoming an integral part of the health care team," Friess adds.