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Clarify your respective roles to create smoother working relationships
Unless you’ve handled things incredibly effectively, there probably is a turf battle going on right now in your hospital. It’s being played out on the nursing floor, behind closed doors, and even during executive sessions. When the case manager walks on the floor, the nurses are probably saying, "OK, let her do it; since she’s here, we don’t have to." They may be dropping their professional responsibilities for a number of things related to coordination of care and discharge planning — apparently a common problem in facilities nationwide.
Bev Cunningham of Case Management Consultants in Tulsa, OK, hears about turf battles from every hospital that comes to her for help in setting up its case management program. "Everyone struggles with it," she says.
Evelyn Koenig, director of case management at Vanderbilt University Medical Center in Nashville, TN, says that to avoid potential problems, case management has to be introduced to a facility in a coordinated, well-planned manner.
Vanderbilt’s case management system came into being rather suddenly when Tennessee Medicaid converted to a managed care system. Case management seemed to be a way to respond to managed care as a process of coordinating the care of the patient across the continuum.
"At first, there was no specific differentiation between what case management teams would do related to the coordination of care and what the nurse would do," Koenig tells Hospital Case Management. "One of the things that is incredibly important in the introduction of case management is to reiterate those responsibilities that remain in the role of the professional nurse."
Cunningham agrees that turf battles — one of the biggest problems facilities have right now — stem from not clarifying to the nursing staff just what it is a case manager does. One thing she has found to be helpful is a responsibility list that identifies what the nurse manager, staff nurse, social worker, and case manager do. She has drawn one up for her clients, and they say it helps decrease turf battles by clarifying roles. (See "Responsibility List," p. 171.)
As Cunningham says, "It’s our own fault that we are where we are today. When facilities put utilization management nurses on the floor years ago, the same thing happened. Nurses said, Who is this person sitting at the desk, breezing though the charts, while I’m working hard?’ We haven’t explained case management’s role to the nursing staff. We haven’t explained that nurses have just as vital a role in case management as case managers do."
Nurses are, in fact, acting as case managers for about half the patients on the floor, depending on clinical and discharge complexity. They manage the cases of patients who are predictable. They do not have utilization responsibilities, but both the staff nurse and the case manager move an individual patient through the system.
The case manager bases her decisions on what has happened to specific populations of patients. "For example," says Cunningham, "case managers know what to expect with pneumonia patients — which ones are most likely not to proceed predictably through the system. Case managers are outcomes-focused." In fact, in many facilities, the term "case manager" has given way to "outcomes manager."
She says it depends on the hospital, but case managers and nurses typically make about the same salary. "But one wears scrubs and one a business suit," says Cunningham, "because one does the bedside work and the other sits at a desk."
Koenig says there are two case management job descriptions at Vanderbilt, one at the BSN level and one at the MSN level, and both of those levels are on a different salary scale from that of the nurses. "That doesn’t mean case managers are making more money than nurses," says Koenig. "Pay depends on the level of nursing experience."
She says a larger salary differential exists between nurse case managers and social workers. Nurses typically are better-paid because of the scarcity of nurses, and the tight nursing labor market has driven up nursing salaries. "Here we have a case of people working at a similar job with similar goals who are paid differently," Koenig says. Social workers are paid less than nurses or case managers not just at Vanderbilt but nationwide, due to the fact that there are more social workers than nurses on the market. "They are not a scarce commodity," she points out.
Get buy-in from your staff
You have to get the nurse manager on the floor to buy into your case management program, explains Cunningham. If the manager buys in and supports it, staff are more likely to welcome the program. How do you achieve that buy-in? "Include them in the decision-making process from the start," she advises, "and keep them educated on what’s going on."
In 1995, Vanderbilt decided to address turf battles by implementing a triad of teams within case management. The teams are structured as follows:
• social worker: crisis intervention, psychosocial assessment, and brief therapeutic interventions;
• utilization manager/DRG specialist: precertification, recertification, concurrent chart review, DRG management, medical record completion, quality data collection;
• nurse case manager: clinical coordination, resource utilization, systems management, analysis/evaluation.
The three sections join as outcomes management, which includes high-risk screening and discharge planning. Within those teams, there is informal agreement on role differentiation. Vanderbilt’s triad works well; the groups cooperate with and rely upon one another. "There are always personality issues, but the model works," says Koenig. "Team building is the key to overcoming turf battles. Give people the tools to work together as teams."
About a year ago, Vanderbilt leaders looked at the triad again to see if this was still the model they wanted to work with. They gave questionnaires to all the team members as well as medical directors and administrative directors of the patient care centers and asked respondents to give their opinion on what was good or could use improvement. The staff responses to the questionnaire validated the model. Everyone agreed that the triad is the key to accomplishing what needs to be accomplished. The facility today continues to work with the basic three teams.
"Everyone agreed that having a team partner with a different set of skills from yours allows the job to get done, and get done in a timely manner," says Koenig. "Initially, there was some concern about whether some people would take other people’s jobs." That was at a time when pure nursing-case management models were being introduced, and there were some layoffs of utilization staff and social workers. There was some concern because nurses were being asked to assume all the roles. "But as it played out," she says, "all the staff became quite comfortable with it. They are dependent on their partners to get the work done."
For more information, contact:
Bev Cunningham, Case Management Consultants, Tulsa, OK. Telephone: (918) 492-6636.
Evelyn Koenig, director of case management, Vanderbilt University Medical Center, Nashville, TN. Telephone: (615) 343-6035.