Merger mania: Your case management department can weather the storm

Establish single standard of care, maintain staff involvement

In the past year, your case management department has assumed responsibility for discharge planning, utilization review, and even social work. You've worked hard at strengthening your department's efforts to span the continuum of care. It's been a hard road, and you've had to deal with limited resources, but you're getting there. Then the bombshell drops: Your hospital's merging with another facility. Now your department's supposed to join forces with another, separate department, and it's up to you and your colleagues to make sure all the gains you've made don't disappear.

For many case managers, that's a familiar scenario. In the first half of 1997, 175 hospitals underwent mergers or acquisitions, according to Irving Levin Associates in New Canaan, CT. And the trend shows no signs of abating.

The problems mergers bring for case managers can seem overwhelming at first, experts say. They include power and control issues among directors of case management, aligning policies and procedures, adjusting job descriptions, dealing with contractual relationships across the continuum, and addressing staff resistance to the inevitable changes mergers bring.

For example, when two major Veterans Affairs (VA) hospitals in Chicago - Lakeside and Westside - merged last year, case managers and staff nurses found themselves embroiled in a year-long transition process full of tense negotiations and difficult decisions. Work groups were appointed for every department hospitalwide, while a central Integration Coordinating Council sought feedback from the mayor's office, the Illinois Nurses Association, and various unions.

For Joe Caldwell, RN, MSN, then chief of nursing services at VA Lakeside, the negotiations were made even more tense when it became clear that only one person - either him or his opposite number at Westside - would be retained to head up nursing services when the merger was complete.

"It was a very painful process," Caldwell says. "Not so much for me, because I was already eligible to retire, but it was obviously a threat to the chief at the other hospital." Knowing that one of them would be let or go or reassigned once the process was complete, Caldwell and the other chief served as co-chairs of the working group charged with integrating their two departments. "At our meetings, we battled on a weekly basis," he adds.

To make matters worse, the central council gave the working group little direction in terms of how the resulting department, or service, should be managed. "We were just given a charge to look at integrating the services," Caldwell says.

One of the first things Caldwell did was appoint task forces within the group to study and make recommendations regarding specific issues, such as how to standardize job descriptions. "We had to make sure that these people were doing the same thing at both divisions," he says. "The descriptions were written up differently, and we wanted to make sure that they were in synch in time for the merger."

One facility can't have two standards of care

More difficult was the issue of establishing a single standard of care for Lakeside and Westside - something Caldwell doesn't think would have been possible if the department had had two chiefs. "The interpretation of the standards can differ depending on who's in charge," he says. "And one of the issues there is that those interpretations can reflect on the salaries of the employees, as well as patient care. You can't operate as one merged facility with different standards of practice and different standards of care fostered by two different people."

Different issues arose in Burlington, NC, when the town's two hospitals - Alamance Memorial and Alamance County Hospital - decided they needed to merge in order to survive. In 1995, the obstetrical departments merged, and by May 1, Alamance Memorial began performing all of the deliveries for the county. The merger also represented the birth of the newly named Alamance Regional Medical Center's case management department, says Brenda S. Holland, MSN, RN, the hospital's CareWays director.

"It was a long merger process to get to the end product," she says. "When we moved into the new building in 1996, I was doing CareWays [clinical pathways], and I knew that case management would have to be a part of this process." In May 1996, Holland submitted a formal proposal to the hospital administration requesting permission to hire two case managers "just to look at managed care," she says. "We were going into this building at probably about 12% managed care. Now we're up to 31%, and we knew it was going to be a big item to look at."

Because of the impending boom in managed care penetration, Holland knew her newly created department would need assistance. That meant merging with social work.

"It was a struggle at first, because social workers don't want to work for a nurse," Holland says. "But after showing them the benefits of working together in a collaborative manner - how it would affect the community, and the patients in this facility, too - they're slowly coming around. My RNs were really gung-ho for it, because they knew what case management is, but the social workers were not really in tune yet as to what the theory entails."

Involve staff in merger process

Case managers and social workers at Alamance are still working out policies and procedures with the help of mediators from hospital administration. "We're sitting down now to decide which policies are valid for whom, and who can work together," Holland says. "Should they go at it as a team approach? Should we all sit down in the morning prior to going out to meet the clients and doctors to decide which cases really need immediate attention? I think it's all going to work out in the end. But we still get a little hesitancy because they want to work as team, but they're not real sure how."

To address the policy coordination issue at VA Chicago, Caldwell identified a "critical group of people" in the working group to merge the policies of the two departments and gave them a specific deadline to meet. Once policies are in place, he says, it's important to review them with everyone to avoid confusion.

"You need to get various inputs from staff or management to make sure everything is covered in the policy," says Cheryl Sangermano, RN, BSN, CNOR, director of ambulatory surgery at Grant Medical Center in Columbus, OH. In Summer 1996, Grant merged with Riverside Methodist Hospital, also in Columbus. "You have to make sure you're all doing the same thing. If you put it in the policy and procedure, you'd better be doing it."

Other suggestions for dealing with hospital mergers include the following:

· Put communication at the top of your priority list.

Give your front-line managers and staff whatever information you have, Sangermano suggests. "If there's things going on up here [in top administration] and they don't hear about it, that's where rumors get started," she says. "Even a little information is better than none at all."

Involving your staff in the merger process helps dispel rumors, Sangermano advises. She used monthly staff meetings to keep employees informed of the status of the merger and to solicit their feedback about how the process was going.

"They need to feel like they're a part of this merger, this change, and their ideas are important," she says. "It's not that we'll always use their ideas, but if they have the opportunity to participate in some of this, it makes it a much easier road to travel. But if you leave them out of it, it's difficult. That's where resentment, frustration, and the 'we/they' idea comes in."

· Be open to change.

"The first thing is that you have to look outside the box," Caldwell says. "Throw away the word 'traditional.' Because you're not only bound by the merger. Health care itself is changing, moving rapidly from inpatient to outpatient. You've got to look at new and innovative ways to get the job done - not compromising anything but doing it more efficiently. Because that's what it's all about; that's why places are merging."

· Involve ancillary departments.

Obtain involvement from ancillary departments, such as risk management, utilization management, and infection control, Sangermano advises. Involving other departments makes the task of merging policies seem less monumental, she says.

· Remain open-minded and flexible.

"I know friends that have been through this and approached it in a negative way by saying, `We've always done it this way. Why do we have to change?'" Sangermano recounts. "Be positive. You'll hit bumps in the road, but you'll get through it."

Not that everything falls into place when you're merging policies, even when you develop a first draft, Holland adds. "It's important to take it slow and look at all avenues before you decide to develop and implement anything," she says. "And look at it as a collaborative effort, because each person's going to be affected. It works better if you have everybody involved sit down with you and help make these decisions."

For more information, contact the following:

· Joe E. Caldwell, RN, MSN, chief of nursing services, VA Chicago Health Care System, Lakeside Division, 333 E. Huron St., Chicago, IL 60611. Telephone: (312) 640-2154.

· Brenda S. Holland, RN, MSN, CareWays director, Alamance Regional Medical Center, Burlington, NC. Telephone: (336) 538-7199.