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Increased opportunities for hospitals mean one more hat for case managers
If you’ve just gotten used to wearing all sorts of new hats as your clinical and financial responsibilities increase, get ready for another one: outpatient case manager.
Already, hospital-based case managers have emerged as perhaps the most important players in ensuring the success of a seamless continuum of care. While a fully integrated health care system may remain years away for many markets, some hospitals already are using case managers to extend services in the emergency department, the community, and especially to outpatient care. And, interestingly enough, smaller, rural hospitals are leading the way in many cases.
Patricia Kohler, CPHQ, CCM, RN, director of utilization management, social services, and discharge planning at Sonora (CA) Community Hospital, says expanding the duties of hospital-based case managers makes sense in terms of both cost and quality. "Case management is about coordination of care," she says. "And when you have a case manager who can bring a case together through any level of care, then you have more effective coordination and cost-effective management of the case. You’re always asking yourself, Is there a better way to do it?’"
At Stamford (CT) Hospital, Trish Babcock, RN, director of case management, is using inpatient case managers as outpatient coordinators for disease-specific populations, including patients with congestive heart failure and diabetes. "What we anticipate doing is looking at utilization issues in terms of accessing care — for example, getting home care as needed," Babcock says. "We want to close the loop in terms of follow-up issues with an outpatient clinic population, because clearly there are situations where there is incorrect utilization. We want to make a more seamless transition for the clinic population from the inpatient setting and be able to provide follow-up care." Stamford’s case management coordinators will focus mainly on keeping patients healthy by facilitating their access to services in the community, Babcock adds.
At Sonora, a small rural hospital with a total bed availability of 73, Kohler’s two nurse case managers perform utilization review, social services screening, and discharge planning. Their average caseload can run as high as 16 to 20 cases per day, and they perform 100% review on all cases. While the hospital’s payer base mix remains slanted toward Medicare, the market is steadily shifting toward commercial third-party payers — a trend that’s creating some problems as the hospital seeks to expand its case management responsibilities. "Our third-party payers each tend to think that they have to create their own utilization review," Kohler says. "I aggressively work with the payers to encourage them to work jointly with us and not make utilization review such a duplicative process. That’s an ongoing, daily effort."
Against that background, Kohler’s case managers are assigned to patients by physicians, and lists are distributed to physicians’ offices, units, and outpatient clinics. "That way, everyone knows which case manager to call," she says. "If it’s Dr. A’s case and the patient is in the emergency department, then the people there know that Karen is the case manager."
In addition, Sonora has compiled a manual of policies and procedures that cross departments, a step that has fostered a less compartmentalized approach to care. "We’ve now broken down the walls," Kohler says. "We’re writing policies to include all other departments and address how we all interface together, including outpatient services. We all use the same manual and the same referral resource list. Whether you’re going into your physician’s office or clinic or coming to the hospital, the manual’s everywhere."
This physician-based approach has been particularly helpful, Kohler says, because it’s provided greater continuity in how cases are managed. It’s also helped shorten inpatient length of stay. Case managers often go to the physicians’ offices to do preadmission screening for some elective procedures. During that process, they also perform preadmission discharge planning. "Then you’re not doing [discharge planning] on the inpatient side," Kohler says. "You’re just checking to see if everything’s the same. So, you’ve shifted your hours to before the admission."
But the physician-based approach has created some difficulties, too, by forcing case managers to shuttle between different care settings. "We have a big campus, with a lot of physician offices," Kohler says. "We also go to the emergency department to meet with patients, as well as to the outpatient clinics."
Given the average number of cases her case managers have to deal with, Kohler is attempting to come up with a flexible staffing schedule that factors in case complexity. Patients with a higher degree of severity would be assigned a higher point value, and if a case manager’s total caseload exceeded a certain number of points (based on number of patients as well as severity), an additional case manager would be brought in to handle the overflow.
"It’s challenging, because we have only two people doing this, with me as a back-up," Kohler says. "If one of my nurses is in a physician’s office for two hours working on admission prevention and looking at placement issues outside of the hospital setting, then I’m out doing her work on the floor. So, you need to have some flexible management leadership to make this work."
Referrals are coordinated with social services, and cases that involve primarily psychosocial issues are turned over to social workers. The social worker coordinates discharge planning and social services for an affiliated long-term care facility.
Kohler acknowledges that her model requires case managers with highly developed skills and an ability to shift easily among a variety of roles. "Some nurses who say they’re case managers don’t do very well in this kind of setting," she says. "Not everyone can change hats so easily. It can be especially difficult for the real purists of utilization review to expand their thoughts beyond just looking at the cost and the setting and the quality to look at the entire continuum. To me, a good case manager is looking at everything almost at once."
Meanwhile, at Clinton Memorial Hospital, a small facility in Wilmington, OH, a new inpatient case management department is seeking out ways to partner with the hospital’s existing outpatient case managers to develop cross-continuum pathways, says Bonnie Davis, RNC, CRNI, BSN, manager of Clinton’s outpatient case management program.
Clinton’s home health division has had both a case management department and a pathway program for years, but within the acute care setting, it was left to the social service department to perform basic case management duties.
Essentially, social services would make the initial referral for home care and ensure that the outpatient case managers received the proper paperwork. "But beyond that, there was no follow-up to see that we actually did go see the patient or how the patient was doing," Davis says. "They would just evaluate the patient as an inpatient, and when the patient was discharged, they were done with him."
In the outpatient setting, each of the four case managers is assigned to a geographical area and manages a caseload of 25 to 30 cases each. Two part-time visiting nurses provide backup when the case managers themselves can’t perform visits. In addition to seeing the patient, the case manager coordinates referrals to home health, physical or occupational therapy, or any other necessary service. "She also continues to coordinate the chart and the patient’s care, and oversees a community resource referral," Davis adds.
Case managers keep patients straight by using a color-coded system of travel folders, along with an area map that locates individual patients by the use of colored push-pins. "So, if a visit nurse sees that she has a red folder on her desk, then she knows who the nurse is," says Sheila Hawley, MSN, RN, clinical coordinator at Clinton.
Davis and Hawley have both been involved in the development of Clinton’s new inpatient case management program, which they hope will integrate smoothly with their own efforts to establish a seamless continuum. The inpatient case managers will be assigned to a physician group and will follow up on patients even after discharge, Davis says. "It may just be a follow-up phone call, but they’ll make sure that the patient’s needs are being met. Our main goal is that we’ll have proper and timely discharge planning and referrals to the proper community resources."
One thing Kohler hopes will come out of the trend toward outpatient case management is the establishment of more productive relationships with managed care companies. "I would like to see payers become a little smarter and understand that they can subcontract work with hospital case managers to run these types of programs in a way that provides cost-effective quality care," she says.
For more information about outpatient case management, contact the following:
Trish Babcock, RN, director of case management, Stamford Hospital, 128 Strawberry Hill Ave., Stamford, CT 06904. Telephone: (203) 353-2000.
Bonnie Davis, RNC, CRNI, BSN, manager, Clinton Memorial Hospital Home Health, Wilmington, OH. Telephone: (937) 382-6611.
Patricia Kohler, CPHQ, CCM, RN, director of utilization management, social services and discharge planning, Sonora (CA) Community Hospital. Telephone: (209) 532-3161.