Restructuring: More hats for case managers

Retraining is key to future success

Your services are more in demand than ever, experts say. But as reimbursement systems move more toward capitation, the field of case management, and your role in it, are likely to change dramatically.

"Case managers are going to have to wear a lot of hats, and I suppose it depends on what you were doing to begin with, whether you consider that threatening, a challenge, or no big deal," says Virginia Irvin, RN, MN, CPHQ, manager of case management at St. Mary’s Health Center in Jefferson City, MO. Those most likely to feel threatened, Irvin adds, are those who have worked in case management departments narrowly defined in terms of utilization review (UR).

"Traditionally, a hospital-based case manager is someone with a UR background or someone who was working as a charge nurse, with hands-on care," says Kathy Moreo, RN, BSN, BPHHSA, CDMS, ABDA, past treasurer of the Case Management Society of America (CMSA), based in Little Rock, AR, and a private management consultant. "Now, suddenly, they’ve been called on to enter into this role of case management."

The problem, Moreo says, is many case management departments were put together "when critical paths were really big, about three years ago, and without a whole lot of understanding about integrated delivery systems." But with hospitals shifting toward integrated delivery and establishing linkages with home care agencies, durable medical equipment companies, and others, case managers are being called upon to expand their knowledge base and tackle a broader array of responsibilities than ever before. "Hospitals are now expecting the case management department to take the patient through the continuum of care — from acute care on — without the adequate training to do case management outside the acute care walls," Moreo says.

Martha Koen, RN, MSN, vice president of the National Institute for Case Management (NICM), also based in Little Rock, agrees that case management today requires a very different set of skills than those typically required of utilization management personnel. "Some folks perhaps can step right up to the plate and fill these jobs, but as case management focuses more on clinical outcomes and processes, I think that the utilization component is only one small piece of the pie."

Don’t neglect refreshing your skills

To adapt to the changing nature of case management, Koen recommends that those with utilization backgrounds refresh their clinical skills and get additional clinical training, if necessary. "That doesn’t mean that people have to go back in and work as a bedside nurse on the night shift to pick up the skills," she says. "But even if it’s just a re-entry for a month or six weeks to get established again, it’s not only beneficial in improving their skill sets, I think it also enhances their credibility with other practitioners. In order to be welcomed into the fold and have the physicians and other clinicians respect their comments or suggestions, they need to feel confident that their clinical knowledge is current."

In the past, says Moreo, "everyone was doing some of the same things and a lot of different things," Moreo says. "Now, they’re taking a step back and saying, ‘well, our lengths of stay aren’t reduced, and we’re still having problems internally and externally. How are we meeting the needs of Medicare and Medicaid populations as they transition into managed care, and why aren’t we able to do it better?’ Because the bottom line is not showing profit for the hospital."

As a result, hospitals are seeking to retrain existing staff and juggle personnel between related departments, says Moreo. "So you’re seeing UR people going to case management and case management people going to utilization management."

In addition, as hospitals move more toward managing chronic illnesses and away from managing only acute episodes, case managers will be challenged to analyze information and "make decisions about options and keeping folks in a state of health," Koen says. "That’s a bit of a different twist. Whereas in the past we focused on catastrophic-type management, we’re now looking at things like disease management."

If your hospital does not offer additional training for the expanded responsibilities it expects of you, Irvin recommends you seek additional information on your own, through networking, trade associations such as CMSA or the Washington, DC-based American Nurses Association, and library and Internet resources. It’s particularly important to learn as much as possible about payment systems that extend beyond the acute care setting.

"That’s probably one of the biggest holes in most case managers’ understanding of the process," Moreo adds. "In addition to knowing community resources, they have to know what will be paid for by the insurance company, what won’t be, and how they can access through social services those items that aren’t picked up through insurance."

Moreo adds that, while most case managers understand Medicare and Medicaid as they pertain to the hospital, most do not have a thorough understanding of Part B Medicare, for example. "Or they don’t understand how a patient’s auto insurance can go beyond hospital walls. And because these hospitals are integrating, and most of the larger hospitals are going to [integrated delivery] systems, that sort of understanding is going to become increasingly important," she says. "Case managers can’t keep the blinders on for any longer period. [At one time] they could say, ‘Well, if it’s after discharge, it doesn’t really pertain to me.’ Now, post-discharge does pertain to them."

The most important thing to remember when seeking additional training is to keep in mind the strategic plan of the hospital, Koen says. "What direction is the hospital taking? Get connected with those types of learning environments that will be skill you for the future of your organization because it varies. Some folks who may be working in tertiary facilities may have different learning needs than those who are in regional or rural hospitals."

Koen adds that more universities are offering curriculum in case management. Such classes can often help supplement a case manager’s on-the-job training and provide a better overview of the job as it’s practiced in different locations. Gaining such education "ought to prepare people academically for the future to meet the challenges of case management and managed care," she says. "That’s really encouraging because these sorts of opportunities didn’t exist a few years back."

[For more information about the changing role of case managers, contact:

Martha Koen, RN, MSN, vice president of the National Institute for Case Management, 10310 W. Markham, Suite 209, Little Rock, AR 72205. Telephone: (501) 227-5400.

Kathleen Moreo, RN, BSN, BPHHSA, CDMS, ABDA, Case Management Society of America, 8201 Cantrell #230, Little Rock, AR 72227. Telephone: (501) 225-2229.

Virginia Irvin, RN, MN, CPHQ, manager of case management, St. Mary’s Health Center, Jefferson City, MO. Telephone: (573) 761-7011.]