Physician-aligned CM model promotes teamwork 

Patients like having the same CM each time

A physician-aligned model of case management has paid off at Danbury (CT) Hospital.

Assigning case managers to physicians rather than units has eliminated the adversarial relationship that sometimes occurs between the two disciplines and increased satisfaction among the staff and patients, says Doris Imperati, RN, BSN, MHSA, CCM, director of clinical resource management.

The arrangement provides the physician and the patient with a single resource for everything, she explains.

"The physician-aligned model works out really well. There is a tremendous amount of satisfaction for the physicians and patients as well as the staff. It has reduced the issues that sometimes arise when physicians and case managers work together," adds Imperati.

A case manager may be assigned to five physicians if they have a large practice or 15 or 20 if the practices are small. The hospital also has eight case managers who work with the hospital’s large hospitalist service.

The assignments are set up so the case manager also is responsible for any physician who would cover for the physicians when they are away.

"The physicians are the people who drive the cost. When each physician has his or her own case manager, they develop rapport and they aren’t offended when the case manager asks them something," Imperati says.

Giving physicians faster access

The case managers all have portable phones with caller identification. If the physician needs the case manager while she’s with a patient, she can see who is calling and step out of the room to take the call. If it’s a number she doesn’t recognize, she can let the call go into voice mail.

"It saves the doctors from having to wait by a telephone for the case manager to answer a page," she notes.

On the rare occasion that a physician complains about a case manager or a case manager complains about a physician, Imperati encourages them to work it out. "Those who don’t are few and far between," she adds.

The system is popular with patients, who often build a relationship with the case managers who coordinate their care every time they are in the hospital.

The arrangement improves patient care since the case manager already is aware of the patient’s condition when he or she is admitted.

For instance, the case manager may know that every time a particular patient comes in, he has issues with his diabetes getting out of control.

"One of the big drivers for success is the leadership of the hospital. They set specific expectations that are goal-directed. They give financial and other recognition to physicians who are cooperative," Imperati says.

The 361-bed hospital has separate psychiatric and rehabilitation units, a health center clinic, and outpatient rehabilitation services, all staffed by case managers and social workers.

Staff include 10 social workers, three of whom work as case managers on the psychiatric unit along with one nurse case manager. The seven other social workers perform clinical social work rather than the typical discharge planning function.

"The hospital has integrated social work into case management, coming up with clearly defined roles for both disciplines and no turf issues," says Imperati.

The department has five clerical support staff. Two are on the unit, helping coordinate the day-to-day details that keep the patient moving through the system, such as arranging transportation and filling in applications for skilled nursing facilities.

The others work in the office, handling data entry, receptionist, and secretarial functions.

The 27 case managers all are registered nurses. Two are in management. One supervises the case manager directly. The other is the clinical quality manager and works with the Clinical Practice Guidelines (CPGs).

A social work consultant comes to the hospital two days a week and provides clinical supervision for the social workers to comply with licensing requirements that supervision be provided by a clinical social worker. The goal of the department is to assess 100% of the admissions.

The case managers handle all functions for the patient, including utilization review for payers; discharge planning; nursing home placement; arranging transportation; and quality management in real time, using the CPGs and the core measures from the Joint Commission on Accreditation of Healthcare Organizations.

"Danbury Hospital has put a lot of resources into the case management department to make sure the case managers are easily accessible and right there to help the doctor get through what needs to be done for the patient," Imperati says.