CMs have trouble adjusting to business mindset
CMs have trouble adjusting to business mindset
OH hospital new to integration
After a huge influx of Medicare and Medicaid patients over the past 18 months, Saint Luke’s Medical Center in Cleveland decided to take the plunge and integrate its case management, utilization review, and discharge planning departments as a way to more efficiently define patients’ plans of care and get costs under control.
"As recently as June of 1996, we were purely a clinical case management group," says Nancy M. Kizys, RN, BSN, director of quality and resource management at Saint Luke’s. An attempt was made once before to integrate case management and utilization, but administration didn’t buy into the idea. "But sooner than later they realized that we needed to," she says. Utilization was folded into case management six months ago, and now discharge planning is being integrated as well. Kizys says adding discharge planning was a necessary next step.
"When discharge planning and case management were separate, case managers did the utilization, and the discharge planner essentially had to find out everything the case manager already knew to make a discharge plan," she says. "Having the case manager do the discharge plan helps expedite things and identifies the needs early on in the case. It also keeps the case manager in touch with everything that’s going on with all the patients."
The transition process hasn’t been easy, Kizys says especially when it came to educating clinical case managers about relating to payers. "Clinical case managers, being nurses, are used to cut-and-dried information," she says. "And the information that they were moving into was never-ending. The plans were hard to learn, and even within each plan, the carriers are not always clear on what it is they cover or what benefit the patient has. There were so many rules and regulations that are constantly changing. We use the word challenging,’ but no, it was difficult. Because case managers don’t want to be secretaries to insurers."
Beyond learning a new type of information, case managers at Saint Luke’s also had difficulty adjusting their perspective from a purely clinical one to one that encompassed business and financial issues. "The business aspect of health care is not really a focus of a professional nurse at the level that utilization is," Kizys says. "It comes across as busy work, as non-nursing work. Yet, we have to advocate for the patient in all of these steps. We have to advocate to allow the patient to be here so he or she can get the best care. We have to advocate so that the insurer understands the need for rehab, so the patient can maintain an optimal level of functional status."
Kizys adds that the additions of discharge planning and utilization management have complemented each other well. "Because, depending on the payer, utilization drives the discharge plan to some degree," she says. "Some payers want you to precertify all home health care. Some want you to use only certain agencies that they’ve partnered with. So even the discharge planning has probably as much utilization as getting the stay approved and having the insurer understand the clinical needs of the patient."
Kizys says that once the discharge planning component is fully integrated, her goal is to have a single case manager covering each patient and coordinating all aspects of that patient’s care. The medical center also is planning to move the new case management department into the emergency department, and is considering expanding into outpatient coverage as well.
For more information about case management at Saint Luke’s, contact the following:
Nancy M. Kizys, RN, BSN, quality and resource management, Saint Luke’s Medical Center, 11311 Shaker Blvd., Cleveland, OH 44104. Telephone: (216) 368-7000.
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