Working with physicians benefits patients’ care

Teamwork is the best way to improve outcomes

The best way for hospital case managers to provide patient-centric care is to get themselves in a position to influence the physicians who are treating their patients, asserts Stefani Daniels, RN, MSNA, managing partner of PHOENIX Medical Management Inc., a Pompano Beach, FL-based consulting firm.

"This came to me as an epiphany many years ago," she says. "Some very noted case management experts find it uncomfortable, but I’m convinced that this is the case because I’ve proven it to myself over and over. If I can engage that physician, I can position myself as a valuable asset to his professional practice and I can impact my patient outcomes," Daniels says.

Case managers naturally want to spend time with their patients, but to truly impact the well-being of a patient in an acute care hospital, they also should spend time talking with the physicians. They should develop a good relationship with physicians so they can influence them to practice more appropriately, practice with evidence-based medicine, and practice more efficiently so the patient doesn’t linger in the hospital unnecessarily, she adds.

Hospital case managers are responsible for affecting the quality of both the clinical and financial outcomes for the patient and the hospital, Daniels points out.

The best way to do this is to work closely with the physicians, she adds.

"The physician brings in the patient — prescribes care, services, and treatment — all of which directly and indirectly influence the clinical and the financial outcomes for the hospital and the patient," she says.

Reducing risk for patients

Hospital case managers should bear in mind that keeping patients in the hospital longer than necessary puts both the patient and hospital at risk, Daniels explains.

"The hospital is the most dangerous place you can be. If a patient is in the hospital over the weekend waiting for an operating room, it adds risk to the patient stay. If case managers truly want to reduce the risk to patients, financial risk, and quality risks, they have got to be able to influence the physicians to keep the hospital stay as short as possible," she adds.

You’re putting your patients and the hospital at financial risk if part of the patient’s hospital stay or a treatment or test is something that his or her insurance won’t cover, Daniels says.

For instance, when Daniels was working with the staff at one hospital, a physician ordered a mammogram for a patient "as long as she’s here."

The woman was being discharged following gallbladder surgery. Insurance companies aren’t likely to pay for a mammogram in the hospital setting when the patient is in for another reason, she continues. "Either the hospital will have to absorb the cost, so this puts the hospital at risk; or the patient has to pay for it, and you’ve added to her financial risk."

Instead, the case manager should point out to the physician that the insurance company is not likely to pay for what is not a hospital-based service and should arrange for the woman to come back for a mammogram after discharge.

"In this case, the case management has eliminated financial risk for the patient and hospital and given the physician the assurance that the patient will get the services at a more appropriate level of care," Daniels says.

Keep in mind that these days patients are likely to have to pay at least part of the cost of hospitalization out of pocket, she adds.

Daniels tells of making the rounds with a case manager who checked the hospital’s Culture and Sensitivity Report to find out which of the antibiotics that were appropriate for a particular patient’s condition was the most cost-effective.

"She told me the patient was going home; and since many patients can’t afford high-priced antibiotics, she would know which was the least expensive so she could ask the physician to write a prescription for that one," Daniels says.

She suggests taking that idea a step forward and doing the same thing for patients who are in the hospital.

"Making sure the medications a patient takes in the hospital are the most cost-effective reduces costs for the hospital. The hospital is the case manager’s customer as well," Daniels says.

Case managers shouldn’t get involved in clinical decisions. Those are the purview of the medical profession. However, she points out, practice decisions may be a result of where the physician went to school, where he or she was trained, and the availability of resources.

For instance, a physician may prescribe magnetic resonance imaging (MRI) for the patient because the hospital has an MRI machine even though a computerized axial tomography (CAT) scan would give the same information.

"Depending on the insurance contract, the patient may get stuck with the bill for the MRI. Or, if it’s Medicare, the hospital may have to give a refund for the extra cost," Daniels explains.

Keeping the cost of patient care down has a far-reaching effect, she adds.

"Case managers should want to keep the payers happy so they’ll want to send all their members to the hospital. They won’t do so if you make them dissatisfied or put their members at risk," she emphasizes.

Case managers can see the big picture in a hospital and are in a perfect position to come up with an innovative operational approach to influence the way care is delivered, Daniels says.

"Case managers are in a perfect position to influence how physicians practice and how care practices are delivered," she says.

Changing behavior

In many instances, hospital case managers spend a lot of their time putting out fires, running all over the hospital, and begging the laboratory or the radiologist to send the results to the physician.

They go on the unit and find out that a patient didn’t get a CAT scan or chemotherapy treatment because they couldn’t be fit into the schedule.

"I take the position that firefighting like this may be appropriate in some circumstances, but in most cases, it doesn’t change behavior. To be effective, case managers need to change behavior," she says.

If the same things happen over and over, case managers should come up with a way to change them. Otherwise, they’re likely to feel overburdened, frustrated, and angry and become openly hostile toward the department in question.

"Radiology isn’t going to change because the case manager begged them to take Mrs. Smith for the CAT scan now. There’s no incentive for them to change," Daniels points out.

Instead of trying to change the way the ancillary services practice, case managers should keep track of the incidents that result in discharge delays and come up with a report that goes to the parties responsible and the chief executive officer.

"Now the case manager is in a position to be able to influence the future," she adds.

Daniels tells of one case management department that was able to identify that 60% of all delays and denials could be traced back to the department of cardiology.

The case managers compiled the data every three months and presented the information to the department of cardiology.

As a result, the cardiology department completely redesigned its processes, brought in a second team, cross-trained personnel, and expanded its hours.

"They revamped the whole cardiology department in response to case management’s objective identification of what their processes were actually costing in days, dollars, and outcomes," Daniels says.

As she consults with hospital case management departments, Daniels urges case managers to look at how they practice case management.

"Some hospital case managers say that case management involves mostly chart review, but case managers could be in those charts all day, and it’s possible to get a clerk to review a chart. For a hospital case manager to be successful, he or she has to talk to the physician," she says.

Going beyond discharge planning

Case management is more than just utilization review and discharge planning, but many case management departments merely are doing expert discharge planning, she adds.

"During the re-engineering craze of the 1990s, hospitals basically consolidated the social work and utilization review departments into a case management department, believing they could reduce the number of [full-time equivalents]. In most cases, people just kept doing what they had been doing because they didn’t know any different way," Daniels says.

True case management involves resource management, reducing variation in patient care, advocating, and coordinating, she adds.

"Reducing variation is what hospital case management is all about. Doctors are busy. A case manager is worth her weight in gold if she reminds him about practice issues," Daniels says.

You don’t have to start from scratch to improve your case management program. You can build on what you have and tweak it just enough to turn it around, she continues.

The first thing a case management director should do is find out what the executive team had in mind when it created the case management department. Make sure the executive team has a clear and targeted vision of what case management is supposed to achieve, and educate it about case management if necessary. The Case Management Society of America standards are a good place to start, Daniels suggests.

After you find out the team’s expectations, come up with a way to ensure that your department meets them and then design the measures to demonstrate when you have achieved your vision.

If you can’t demonstrate the value of your case management department, your job may be at risk, Daniels asserts.

Daniels offers other tips on how case management directors can improve their departments:

  • Look at your department’s structure to determine what kind of staffing you need. You may be able to use clerks for some functions rather than having all registered nurses.
  • Don’t forget to include social workers on your case management team.

"Social workers have an expertise that no other person has in regard to the kind of patient we’re seeing in the hospital today," she says.