How St. Vincent Mercy handled its turf problems

Outcomes manager replaces three other jobs

Robin Bender, RN, director of the outcomes management program at St. Vincent Mercy Medical Center in Toledo, OH, says her facility’s inpatient disease management department was restructured recently. Prior to January 1999, the department consisted of nurses working as quality management analysts who were responsible for quality aspects of utilization management, a few nurse discharge planners, case managers, and social workers. The case managers could be unit-based, service-based, or physician-specific.

"It was a fragmented system," says Bender. "You would frequently hear comments like, Well, we don’t know what case managers do.’" There was little consistency from one case manager to another in terms of how they functioned, how they reported the achievements they made with certain populations, or what obstacles they were encountering. And there was no mechanism in place to feed back that information.

"We looked at the roles of those groups of people as well as of the social workers and ended up restructuring," she says. "We eliminated those original three roles — case manager, nurse discharge planner, and quality management analyst — and replaced them with a new role called outcomes manager." The displaced employees were given the opportunity to apply for the new position.

The outcomes manager is responsible for utilization management, case-managing the complex patient, and simple discharge planning, such as setting up home care and transporting patients home.

"In her role as utilization manager, the outcomes manager is in constant contact with the insurers, and that improves our ability to do discharge planning," says Bender. "We know up front if a patient has a preferred provider, who it is, and what kind of services are covered. Previously, we had to wait until we got a referral and then wait for someone else to find out that information."

When the reorganizers at St. Vincent folded existing positions into the new outcomes manager position, they weren’t looking at decreasing the ranks of full-time employees, Bender says. "That was not our goal. We were looking at improving our program so that we could improve the outcomes relative to our patient population." They actually increased the number of people doing case management. It also freed up the social workers to do the things they are trained to do — investigating abuse and neglect cases, financial counseling with patients and families, guardianship issues, and complex discharges to rehab or subacute care.

"We focused energies on tasks that people were trained to do. Before our reorganization, staffers had been doing jobs they weren’t trained for." Communication between the case managers, quality management analysts, and nurse discharge planners had been limited. Bender dealt with that by putting everyone through a comprehensive training program. There is also new resident orientation at St. Vincent on a monthly basis to let the rotating doctors know what social workers and outcomes managers do. "We give all residents a list of the individuals with their pager numbers so they can keep in touch," says Bender.

"Now we have outcomes managers and social workers who are team-based," she says. Teams are driven by clinical area. For example, critical care teams comprise the medical-surgical ICU, the step-down ICU, and the burn unit. There is a cardiovascular team, a med-surg team, a neuro-orthopedic team including trauma recovery, an obstetrics team, and a pediatrics team. A float team is cross-trained in all those areas to cover when others are on vacation or other leave.

"As we restructured," says Bender, "one of the issues that came up from the nursing staff was the comment, You’re just trying to get the patient out of the hospital quickly.’ Then we had a situation where the nursing staff would refuse to share information if they thought that information might mean that we were looking for an alternative setting for a patient." She explains that, of course, the outcomes staff were not trying to push patients out of the hospital but were looking for the most appropriate level of care for patients based on their needs.

Spending limited funds wisely

"Insurance supplies a finite number of dollars to cover a patient during his lifetime," Bender explains. "If we use a portion of those dollars unnecessarily, and something catastrophic happens, the patient will have fewer resources to pull from. We look at what is medically necessary for the patient and take everything into consideration."

Another perception of the nursing staff was, "We’re very busy doing direct patient care. We don’t know what you case or outcomes managers are doing, so why don’t you help out and do direct patient care?" Bender echoes the other experts in saying this is a battle that still must be fought constantly. The situation is only overcome when the outcomes managers excel and accomplish interventions that work.

"Then they overcome those assumptions," says Bender. An example, she says, is that now patients are discharged directly from St. Vincent’s ICU. "That never happened in the past," she notes. The outcomes manager facilitates patient care conferences with physicians, families, and staff. They discuss the chances for recovery and the plans of care. All the information is shared with the nursing staff.

"From that perspective, the nurse sees the outcomes manager’s role as valuable," Bender says. "She might think, She has gathered valuable information that I have not had the time to get on my own.’" The nurse’s perception of the outcomes manager depends on how the outcomes manager has integrated herself into the clinical areas and is working with the staff. It is then that the staff see what kinds of opportunities they have for additional information that they didn’t have before. It’s now a centralized process, where it wasn’t before.

"We have to prove that we are a valuable member of the nursing staff’s team," Bender says. "Our day is spent out on the nursing unit, not in a central office. We are accessible to the staff and physicians, trying to get everything coordinated." But, she says, the program is only as successful as the individual outcomes managers are.

"Overcoming barriers and turf battles is a day-to-day, person-to-person problem," she says, "but we’re dealing with them. If one tactic doesn’t work, there’s always another way."

For more information, contact:

Robin Bender, RN, director, outcomes management program, St. Vincent Mercy Medical Center, Toledo, OH. Telephone: (419) 251-4105.