Do patients get uniform case management?

Perform assessment of CM practices to make sure

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

The leadership standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) require that hospitals provide "one level of care" for all patients. The intent of this standard has been clearly defined by the Joint Commission to mean that patients who have the same health problems and health care needs will receive the same level of care or resource allocation regardless of time of service, place of service delivery, or ability to pay.

For case management departments, this requirement can be problematic. Case manager staffing patterns and screening criteria may need to be adjusted to ensure availability of case management services to all patients needing such services.

Understanding the intent of the standard is key to a successful survey as well as success in providing consistent and uniform case management services to all patients. The Joint Commission clearly recognizes that different patients have different health care needs and that each patient’s individual circumstances dictate the level of case management services needed for a positive outcome.

Response times for case management assessments and interventions should be the same for patients with similar needs, regardless of whether they are admitted on a weekday, weekend, or holiday. An approach case management departments can use to meet this requirement is through the development of a strategy and plan for the provision of patient care. The plan must be consistent with the mission of the organization, be expected to produce consistent and positive patient outcomes, and take into consideration the specific skill levels and competencies of the case managers who will provide the services.

In determining the departmental plan for case management, a delivery model should be selected.

The model for providing case management services may involve assigning case managers to particular units or patient populations in order to efficiently deliver services to the appropriate patients. Once the delivery model is determined, the department must clarify how patients needing case management will be identified and how resources will be allocated to meet those needs. Policies that specify all patients will be assessed at specific frequencies based on the day of the week are outmoded and inappropriate. Do your case management policies state, for example, that patients admitted Monday through Friday will be assessed within 24 hours of admission and others will be assessed within 72 hours? If so, you clearly are not providing consistent care based on patient needs. The time frames must be the same for patients with the same needs.

It is acceptable to have different assessment time frames for different populations based on the real needs of patients in those groups. For example, patients admitted to the critical care unit may not require an assessment of their discharge needs within 24 hours of admission, but this time frame may be appropriate for patients admitted to a medical unit. For specific patient populations, such as orthopedics, it is appropriate to have a policy that states that acute care patients with a given set of diagnoses will receive an initial assessment within a shorter time than patients with the same diagnoses who are admitted to a long-stay unit.

It is imperative that the time frames for initial case management assessment be established without consideration for the case manager staffing schedules. A policy that specifies that patients will be evaluated within "24 working hours" implies that the needs of the staff have been considered rather than the needs of patients. Likewise, time frames for initial assessment should not be linked to the patient’s ability to pay or type of insurance coverage. All patients with similar clinical or psychosocial needs must receive timely and appropriate case management services.

When faced with limited case management resources, there may be situations where all patient needs cannot be met. It is acceptable to prioritize patient needs based on an acuity system that allows for high-priority needs to be addressed more quickly than lower ones. Variables of illness severity can be used to establish a system for prioritizing case management services. These variables include age, specific complications and comorbidities, level of effect of complications and comorbidities, direct clinical and physiological observations, need for life-support or therapeutic interventions, admission status, and anticipated discharge status. Look at having a case manager on call to respond to specific needs on weekends and have criteria that trigger case management interventions. By triaging patient needs based on established policy, the case management department is able to assure consistent levels of service.

Review a representative sample of charts and determine what level of case management intervention was provided to meet the high-priority patient needs that were identified during the initial assessment. Determine what your staffing requirements would be to provide just these interventions on a 365-days-a-year basis and make this your core staffing level. This would be the staff you schedule every day. Determine what medium- or low-priority case management interventions you could provide with additional staff on a certain number of days and flex staffing up and down as appropriate.

Assess your current activities

Perform your own assessment of case management practices to determine if a uniform level of services is being provided. Start this assessment by examining the language in your policies. If you find that you use language that suggests different case management coverage on different days of the week or that you refer to time frames as "working hours," it’s time to critically evaluate your policies. While having coverage policies that relate to the weekend may not always be problematic, this type of language could trigger a more intensive review of your coverage practices by a JCAHO surveyor.

Look at your staffing to determine if it meets JCAHO requirements for uniform performance of patient care processes. Suppose you work in a 65-bed rural hospital and you are one of two RN case managers. There also is one part-time social worker who is available two days a week.

Case management services routinely are provided only on weekdays, with one of the two case managers on call each weekend. This staffing pattern would appear to show a different level of service based on the day of the week and could put your department at risk for not providing uniform care if patients routinely required the services of both a case manager and a social worker. A review of case mix and patient needs would be needed to determine if patient needs are being met. If, for example, the patient mix is generally low-risk medical and all high-risk patients are being transferred elsewhere, the staffing may be adequate as long as patients meeting your department’s criteria for case management intervention are being seen.

Of particular concern might be how patients with psychosocial problems are being assessed and appropriate discharge planning initiated. If the RN case managers are cross-trained to conduct social work assessments, staffing may be adequate. If the department has criteria for selecting high-priority patients for case management or social work interventions, an audit may reveal that all of these patients are in fact receiving necessary services in a timely fashion.

Another area of potential problems is case management based on the patient’s payment source. Patients covered by insurance that is expected to adequately reimburse the facility for an entire hospitalization should not be considered low priority for case management services. Decisions about whether a patient requires case management services must be based on the patient’s needs, not expected payment. Some of the case manager’s struggle is to find sufficient time for every patient; however, providing a uniform level of care means seeing all patients who meet criteria for case management interventions. If the workload is too high to ensure compliance with the department’s policies, it may be necessary to revise the case management triage criteria or add additional staff.

The JCAHO survey team will expect to see that your practice actually follows the policies you have in place. If you find your policies and practices are different, assess the cause of this disparity. Often policies become outdated and new practices are accepted without updating written policies. At other times, policies are appropriate, realistic, and effective but staff members require education and feedback to ensure compliance. Take time to evaluate whether case management is provided uniformly to all patients based on their needs and whether actual practices reflect your department’s policies.

If your department is in compliance with the JCAHO standard for uniform patient care, continue to monitor staff adherence to policies. If you find areas out of compliance, take steps to remedy the problems.