How to steer your case management program through tumultuous mergers

Survival tips from veteran case managers

The announcement is made: Your facility is merging with a local competitor. Rumors start to fly that jobs will be cut and responsibilities will change. What will happen with the case management program you've worked so hard to establish, and will you have a role in the new system?

Case managers who have been through the tumultuous process of a merger or alliance have good news: Case management is continuing to be a high priority in the new health care systems that are evolving from mergers and acquisitions.

In fact, developing critical paths and establishing a joint case management program can strengthen ties and establish a common ground for the providers involved in the upheaval -- despite the highly charged emotions and corporate policy overhauls that come with the change. It's not easy, but a merger or new alliance could be the booster shot your case management program needs to expand, experienced case managers tell Hospital Case Management.

"The merger is giving us the opportunity to do different things. Now our case management program is on the leading edge because we have a community and an inpatient piece. The merger allows us to share information with the other campus, and we're not competitors now," says Margaret Reinert, RN, BSN, MSN, director of outcomes research and quality management at the newly formed Via Christi Regional Medical Center in Wichita, KS.

Via Christi was formed in October 1995 when 886-bed St. Francis Hospital, 600-bed St. Joseph Hospital, and a local freestanding rehab hospital merged. Integration of case management functions is occurring primarily between the two acute care hospitals, says Reinert.

For some hospitals, a merger can herald the arrival of case management. That's what happened when Harford Memorial Hospital and Fallston General Hospital, both located in Harford County, MD, merged to create Upper Chesapeake Health System in May 1995.

System administrators suggested which critical paths should be developed, but allowed flexibility in how the program would be structured, says Arlene Swarthout, RN, MSN, director of clinical resource management. The hospitals merged to prepare for an anticipated increase in managed care contracts at the rural hospitals.

Chances are strong that if you haven't been through some sort of new merger or network alliance, you will. Hospital merger and acquisition activity reached its highest level in two years during the second quarter of 1995, according to New Canaan, CT-based Irving Levin Associates' Health Care Merger & Acquisition Report. During that quarter alone, 31 hospital transactions were announced, an increase of six from the quarter before. In all, 112 hospitals were affected.

The issue of mergers and acquisitions also ranked as one of the top five concerns among case managers in the 1995 Hospital Case Management Reader Survey.

Reinert and other case managers who have been through the merger process offer the following tips for case managers:

* Ask specifically how your department will be affected.

Knowing what changes in personnel and policies senior management has in mind is half the battle in making it through the early stages of a merger. Ask whether policies and procedures will stay the same or be rewritten. Also ask about departmental structure because some traditionally independent departments may be combined.

"All of the policies were combined and rewritten, including pathway development policies. We also had a complete review of salary structures, and the utilization review and social services departments were combined into a utilization management department," says Tracey Moffatt, RN, BSN, director of utilization case management and social services at Mercy Regional Medical Center in Laredo, TX. Moffatt previously served as pathway project manager when her former employer, Mercy Hospital in New Orleans, merged with cross-town Baptist Hospital in 1994 to form Mercy Baptist Health System. Moffatt was promoted to her current position in the system in 1995.

Via Christi's system administrators allowed staff from each case management department to get to know each other before implementing systemwide changes. "Some of the merger activities are still occurring, but we were given three months from the time of the announcement to the actual merger, so we met our counterparts, and we're in the process of sharing information to make a better program," says Reinert.

* Appoint coordinators at each facility involved to smooth the transition.

Moffatt was hired as pathway project manager to oversee critical path development for the new system's two campuses. Her first action was to appoint pathway coordinators at each facility. "I appointed nurses who had been at each hospital as coordinators because we didn't want to rock the boat," explains Moffatt.

Moffatt's duties as project manager were to supervise the implementation of pathways through the coordinators at each campus, present new pathways to medical and nursing staff, and solve implementation problems with the help of department directors. Moffatt divided her work week by spending two days at Mercy and three days at Baptist because Baptist had about 100 more beds. "I tried to attend every meeting I could and make myself known to all staff," she adds.

Pathway coordinators helped establish buy-in from nursing and medical staff at each campus. The coordinators handled daily issues concerning pathway implementation and conducted pathway development meetings at each campus, says Moffatt. (For more on this model, see the story, p. 20.)

Upper Chesapeake also is using the director-coordinator management structure. Swarthout recruited Nancy Glenn-Molali, RN, MSN, CRRN, nurse case manager, in September 1995 and hired another case manager in January 1996.

Each of the nurse case managers works at her own hospital, but can be called on to work at the other facility when needed, says Swarthout. As director, Swarthout consults with each case manager and provides assistance in implementing new critical paths.

* Get away from the turf.

Before pathway development began at Mercy Baptist, Moffatt and her coordinators got to know each other personally and professionally away from the work environment. "Case managers first need to come to an agreement because if there's fighting among the case managers, the program will never last. By meeting each other away from work, the turf issues were not as prominent, and we all agreed on three goals: to remain positive, to not lose momentum, and to not get involved in politics," explains Moffatt.

* Define a mission and develop a time line for systemwide goals.

A systemwide mission, or direction, should be established, including a time line for achieving goals. "The first six months were spent closed up in an office developing the program and establishing multidisciplinary pathway development teams," notes Swarthout.

When Mercy merged with Baptist, case management was just beginning at Baptist, and "they operated very differently, even though we were four miles apart," says Moffatt. Moffatt and her two coordinators established a goal of developing 20 new paths that both facilities would use.

* Let the medical staff tell you which paths they want to work on.

Senior management at Upper Chesapeake decided which DRGs should be the initial focus of pathway development, but then Swarthout opened the pathway development process to all medical staff to identify additional paths they would find useful.

"I told the medical staff that if they felt a path was valuable to have, we could develop it. That's how we ended up with pediatric asthma, chest pain, and laparoscopic cholecystectomy. Some staff felt the angina path didn't fit well in the emergency department, so they developed the chest pain path," explains Swarthout.

Multidisciplinary staff representatives from both campuses attended systemwide development meetings for each pathway. "Whatever the systemwide team decided was brought back, so a consensus was built on a final document. This took longer, but the strengths from each team led to a better path," explains Glenn-Molali.

Upper Chesapeake's systemwide efforts at implementing paths will be enhanced later this year when the system installs a computerized clinical documentation system, says Swarthout. Case managers will be able to analyze their efforts on a cost-benefit basis when the system is installed in April. Swarthout also is exploring the possibility of having development meetings through teleconferencing technology to help facilitate future path development. "The facilities are 30 minutes apart, so frequent meetings are not feasible," says Swarthout.

The biggest hurdle for Swarthout and Glenn-Molali was getting pathways used on a daily basis. To encourage pathway usage, both Swarthout and Glenn-Molali drop by each unit shortly after a new pathway is introduced to answer questions or handle problems staff may have. "I get my boost when I see staff with limited knowledge of case management and critical paths using the path and see the concept click with them," says Glenn-Molali.

* Create a path development notebook.

Allow staff to document suggested changes to pathways in a notebook that is accessible to the staff using the paths. The documentation notebook should be kept on the unit where the path is used and should include a signature from the physician requesting the change. Keeping track of this information ensures that revisions are made in a timely manner and that physicians agree to the changes before the new path reaches the unit.

"Our system had an in-house word processor, so we made the changes to the paths, swapped them out, and documented it in the notebook," explains Moffatt.

* Make the change fun.

Try to make changes associated with pathway development fun. Open houses, dinners, or theme parties are good ways to introduce new critical paths to staff.

"We introduced our total hip pathway . . . with a football theme. Day one was on the 20 yard line, for example. We got a medical supply sales representative to supply femur-shaped pens and sponsor a dinner, as well," Moffatt says.

Posters advertising a new path also work well on individual units. Pathways were placed on posters and hidden behind a felt curtain with the headline "Coming soon," she adds.

* Keep communication open; be available for help.

Constant communication helps counteract any negative criticism from staff. Moffatt also recommends allowing three-day weekends whenever team leaders show signs of burnout or stress.

Medical and nursing staff are likely to use the paths if they know that designated staff are available to answer questions, help solve problems, or just observe to see if pathways are being used.

"We didn't come out of our office for the first six months during the development of our program, but once it was complete, we were out every day. We gained the reputation on some units as being the 'pathway patrol.' Just being available helps a lot," says Swarthout.

* Don't try to do too much.

Regardless of the approach, keep the process simple, urges Connie Curran, RN, EDD, president of CurranCare, a health care consulting firm in North Riverside, IL. While the hospitals in your system may work best with shared paths, others should use different paths in different hospitals. Traditional paths may not even work in some systems.

"I'm working with a system with seven hospitals. Each one has made valiant efforts at creating critical paths, but I think generally, people still tend to be process-oriented. They are putting way too much focus on generating multiple-page paths, where I think in expert systems, it almost comes down to a sheet of standing orders," says Curran.

[Editor's note: To request a copy of the Health Care Merger & Acquisition Report, contact Irving Levin Associates, 72 Park St., New Canaan, CT 06840. Telephone: (203) 966-4343. The annual subscription rate for the quarterly publication is $950.] *