Reorganization merges UM and social work

Cross-trained staff provide case management 

Almost as soon as Homestead (FL) Hospital implemented an integrated model of case management, patient satisfaction scores went up and lengths of stay started to decline.

"Almost immediately after we went live, we noticed an improvement in our patient satisfaction scores related to discharge planning. We were able to impact length of stay quickly, within the first couple of months; and we continue to make progress in that area," says Jill White, RN director of performance improvement and case management.

The patient satisfaction questionnaire asks patients to rate the extent to which they felt ready for discharge and how well the home health care services were handled.

"Our scores went up dramatically almost immediately after case management was implemented," she says.

The department has gotten a lot of positive feedback from physicians, nursing staff, and patients who like the new model, White says.

The hospital is just beginning to get the information it needs to see the impact that the new program has had on revenue, she says.

"It takes about five months to be able to see a difference in cost data, and we’re only beginning to get to that point," she says.

Until earlier this year, the hospital had a utilization management program staffed by RNs and a separate social work department that performed discharge planning.

When the two departments merged in the spring of 2004, the nurses who handled utilization management and the social workers who took care of discharge planning were cross-trained to do both roles. Now, staff from both disciplines are called case managers and have exactly the same job descriptions, performing functions traditionally handled by both disciplines.

The case managers coordinate patient care on the hospital units, in the emergency department (ED), and in the transitional stay unit (where patients are moved for observation or when they’re being admitted from the ED and are waiting for a bed to become free).

The hospital made the decision to create an integrated case management model at a time when the average daily census was increasing and the average length of stay was going up.

"Our average length of stay was in line with that of other organizations, but when we drilled down on individual cases, we found that there were opportunities to better manage the care of patients who were in the hospital for 10 days or longer," White says.

White’s department searched the literature to find out what other hospitals were doing and talked to a New York hospital with a similar patient mix and lower lengths of stay.

The hospital made the decision to create an integrated model that combines the social work and utilization management department into a case management department.

The hospital has two inpatient floors with three case managers assigned geographically to each. Every case manager carries a patient load of about 15, whether they are a nurse or a social worker.

There are two case assistants, one for each floor, who make copies and telephone calls and handle other clerical duties, freeing up the case manager to spend their time dealing with patient care issues.

The case assistants had a similar role in the social work department before the merger.

"They’re right on the floor working closely with the case managers and providing whatever assistance is needed. They make a lot of phone calls, contacting home health agencies and assisting with setting up services," she says.

The department decided to assign the case managers geographically after getting feedback from the physicians and nurses.

"We contemplated having the case managers follow the patient from admission through discharge. The physicians and nurses felt that having case managers go from one unit to another could create a situation where they might miss some information and lose opportunities to talk with the physicians," White says.

All staff have the same job description, whether they are nurses or social workers.

"We spent a lot of time cross-training them on the other discipline’s functions," White says.

Each case manager, whether a nurse or a social worker, is responsible for the care of 15 patients. Both disciplines track clinical information, conduct utilization review for payers, and handle discharge planning.

"With the two different disciplines, we have a good mix of experience and expertise. They learn from each other and are able to handle anything that comes along," she says.

The staff underwent extensive training in the beginning of 2004. The hospital did a two-week pilot project in March 2004 to iron out any last-minute kinks and gradually went live on the other units.

McKesson Corp., based in San Francisco, presented a three-day training program for all the staff. A big portion of the training included how to review a medical record for clinical criteria.

"We felt that area was one that might be a challenge to the social workers who do not have a nursing background," White says. "Our social work staff was very experienced. They had worked in the hospital for a long time and had picked up a lot of knowledge about clinical aspects of patient care."

When the new model went live, staff started off with a smaller caseload than what they now handle. "They trained each other case-by-case. The nurses trained the social workers to review for clinical function, and the social workers trained the nurses about discharge planning," White says.

The nurses and social workers saw the patients together as long as they felt it was necessary. The case managers on each floor have a case conference every day to discuss any cases that may be challenging. "They learn from each other. The cooperative relationship has really been successful," White says.

The case managers take their laptop computers to the floor with them, using data ports on each unit. The hospital uses the MIDAS+ care management system software from Affiliated Computer Services (ACS), a Dallas-based information technology firm, for utilization review and discharge planning.

"The case managers are on the unit all day, easily accessible to the physicians and patients. They visit each patient each day," she says.

Before the integrated model was put into place, social workers saw patients only by referral from nursing or utilization management staff. If the referral didn’t take place until the end of the stay, the patient often was not discharged in a timely manner.

Under the new system, all patients are seen by case managers, who start the discharge planning process upon admission.

The new model includes a patient transfer case manager who makes arrangements for patients with complex conditions who are being transferred to a facility that can provide a higher level of care.

Homestead is a 120-bed facility that doesn’t offer some services, such as cardiac catheterization, thoracic surgery, cardiovascular surgery, or neurosurgery.

Before the new model was implemented, the nursing staff handled the transfers.

"It was a difficult job that nursing tried to do along with providing direct patient care. We had patients waiting multiple days to transfer to other facilities. Having a person dedicated to doing the hospital-to-hospital transfers has been a key component to reducing length of stay," she says.

Covering weekend duty 

The hospital has abbreviated case management staffing on the weekend, with one case manager working on the floors each weekend day. Staff take turns handling the weekend duty.

"More managed care organizations are open on the weekends, and some require that clinical information be available seven days a week. We have patients who are ready to be discharged on weekends and need someone to facilitate that," White says.

Most of the discharge planning for weekend discharges is set up during the week, but the case managers are on hand if there is a discharge that wasn’t expected or someone being discharged needs additional services. The weekend case manager also coordinates with the ED case manager to take care of any needs of patients being admitted.

Case managers covering the ED are all registered nurses who work 12-hour shifts and rotating weekend duty. The ED case managers were the hospital’s first case managers and have been in place for two years.

"The emergency department case managers ensure that the patients need to be in the hospital and make sure that the patients who are discharged from the emergency department have the appropriate resources, such as durable medical equipment. They make sure they know where to follow up. If they are being admitted, they get the initial clinical information and start the discharge plan," she says.

Creating the ED case management role has helped the hospital move patients through the continuum of care in a timely manner.

"In the past, the utilization manager wouldn’t have seen the patient until the day after they were admitted, and it might have been as long as 24 hours later," White says.

The case manager for the transitional stay unit works an eight-hour shift Monday through Friday. She watches the patients on that unit closely and makes sure the test results get to physicians in a timely manner. She does utilization review, making sure that the patient is in the correct setting, whether inpatient or outpatient, and ensuring that the documentation is correct.

"These are patients that the hospital wants to manage more aggressively to either admit them to inpatient status or rule out a clinical condition that warrants hospitalization," White says.

The shift to an integrated model of case management was accomplished without an increase in budget and using the existing staff, White says.

"We took the current staff in each area and cross-trained them. At the time, we had the emergency department case management position staffed 24 hours a day. We decided we could make a bigger impact by having case management during the day and shifting some of the emergency department FTEs to the floor case management," she says.