Give outcomes managers responsibility for continuum-of-care issues

Free case managers to manage episodes of care

With many hospitals collapsing virtually all their quality-related departments into case management, some case managers worry that the added administrative workload could interfere with their ability to clinically manage patients. But now, some hospitals have found a solution they say eases the burden on case managers as well as allowing for more effective population-based management of patients along the continuum. The answer: giving outcomes managers responsibility for the "big picture" of cross-continuum care.

"The problem is that it’s hard for case managers to focus on the tasks of the day and get patients through episodes of care if they’re also trying to run teams and coordinate data," says Connie Rowe, RN, CPHQ, director of quality, utilization, and risk management at Enloe Hospital in Chico, CA.

"There’s no question that case managers are overloaded," agrees Michael Newell, RN, MSN, CCM, a managed care consultant in Merchantville, NJ, and author of Using Nursing Case Management to Improve Outcomes. "The expectations are too high and they have too many patients. They’re often doing what discharge planners, utilization review nurses, and quality improvement nurses do all rolled up into one. And there’s not the support infrastructure there to do all those things when the caseload is up to 30 patients or more."

At Enloe, Rowe was aware of the danger of overloading her team when she and her colleagues were asked to assemble a case management department. At that time, the hospital still had separate staff for utilization review and discharge planning. "So the first thing we did was combine those two roles so those people were looking at the patient’s full episode of care together rather than separately," Rowe says.

With that step accomplished, they turned their attention to the needs of their specific patient populations. In particular, they identified their high-volume and high-risk populations and used clinical nurse specialists or nurse educators from those areas to perform a separate function: outcomes management. Now, one outcomes manager is assigned to each of three areas in the hospital: CV/pulmonary; hematology/ oncology; and trauma, neuro, and ortho.

"Each of the three of us had worked in our specialty area for years," says Carol Butler, RN, CCRN, outcomes manager for trauma, neuro, and ortho at Enloe. "For example, I was the charge nurse in the neuro/trauma intensive care unit. We were educators and had more of a specialized clinical focus."

At Enloe, case managers focus more on the needs of individual patients, both clinically and financially. Butler notes that about half their time is spent on discharge planning. Outcomes managers, on the other hand, focus on the entire service line, Butler says. "We look at an entire population of patients," she says. "And we get involved in the specific episodes if problems arise. In this facility, we’re used very much as clinical nurse specialists with a focus on structuring services in such a way that we can maximize resource utilization and keep our patient care quality as high as possible."

The outcomes managers’ specific responsibilities differ according to specialty, but they’re all involved on some level with coordinating patient care across the continuum. For example, one of the goals of the outcomes manager for hematology/oncology is to make sure her patients remain outpatients. Because Butler is responsible for trauma, most of her patients need acute care, but she’s also responsible for a brain attack program that monitors and tracks patients after the inpatient stay. Also, two of the outcomes managers have taken responsibility for tracking patients engaged in clinical trials at the hospital. "[Our responsibilities] are largely tailored to whatever’s going on with the population of patients at that time," Butler says.

Particularly in areas of high managed care penetration, outcomes management has emerged as a role separate from but related to case management. In particular, the emergence of outcomes management has been driven by the need for hospitals to get a better handle on patient populations outside of hospital walls, says Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Canton, MI. Some experts claim it probably isn’t possible for one person to effectively manage individual patients in the acute care setting and at the same time maintain a continuum-based focus on an entire population of patients.

Others, however, say case managers haven’t been used enough when it comes to quality improvement. "Case managers are in an excellent position to see and hear all the quality problems as they unfold," Newell says. "You don’t need to case-manage people who are doing just fine, who are going to blow right through their critical path or have an uneventful hospital stay." Instead, case managers should be focusing on bringing outliers back under control. "If it’s a well-functioning case management program, then case managers are in an excellent position to collect the kind of data that can tell you how you’re doing on a day-to-day basis. So why not build in some kind of quality improvement/outcomes measurement program that can give you adequate feedback on how to tweak your program and improve your processes?"

However, at Grant/Riverside Methodist Hospitals, a hospital system in Columbus, OH, administrators believed the system’s disease management efforts required a role that "embraced research," says Carmela Hartline, MS, RNC, director of disease management services and director of heart services. "We are a large research facility, but we didn’t have a separate research department. That responsibility remained within the service lines. But case management was not the [appropriate] role for that."

Hartline and her colleagues took a long look at case management two years ago, when Grant Medical Center began merging with other hospitals in central Ohio. The purpose was to develop a cross-campus case management initiative with standardized responsibilities. (For a list of case management and outcomes management responsibilities at Grant/Riverside Methodist, see box, above.)

Out of the case management initiative, Hartline and her colleagues in heart services realized that they had "a huge void in following populations of patients," she says. "Case managers geographically assigned to the unit rather than to phy sicians. But we needed a role that oversaw a whole population of patients — not just from a case management perspective but from a population/disease management perspective. That’s why we developed the outcomes management role."

As they conceptualized the outcomes management role, Hartline and her colleagues decided outcomes managers should be master’s-prepared and clinically astute. "They needed to be able to identify pathway variances, care for the patient, and communicate readily with the physician group," she says. At that point, some of the case managers weren’t quite at that level of clinical expertise. "They were utilization review folks," Hartline says.

Hartline says she requires an MS for outcomes managers because it lends credibility to the role. It also means candidates are more likely to have expertise in resource utilization. "Outcomes managers here look at the entire population of patients through the continuum — not just acute care," Hartline says. "They look at the time prior to the patient getting here, while they’re here, and then they do functional outcome follow-up after acute care."

Meanwhile, case managers focus on following patients through the acute care setting. "They may have some precertification responsibilities, but they aren’t really responsible for pre- and postacute care."

Although their roles and focus differ, case managers and outcomes managers work together on population-based teams. The teams are led by the outcomes manager and a physician, who coordinates the day-to-day care of the population. In addition, case managers, who work on the units every day, enter outlier data into a computer system called MIDAS. "They sometimes identify the variance, and then the outcomes managers follow it through," Hartline says. The outcomes manager then communicates the data to a multidisciplinary work team and analyzes the information to determine possible process improvements or changes to a certain protocol or pathway.

But an outcomes manager at Grant/Riverside Methodist doesn’t just crunch data. She sees patients in the acute care setting and also takes responsibility for managing patients in the outpatient heart disease management clinic. "She provides that continuum of care all the way through, which gives great continuity," Hartline says. "She knows the patients along with the cardiologists who are caring for them."

To ensure that case managers and outcomes managers work effectively together, Hartline has work teams meet every month to discuss the patient population. Rowe has taken a similar approach at Enloe, where case managers and outcomes managers hold joint staff meetings. In addition, case managers often serve on "focus teams" facilitated by outcomes managers, and both participate in what Rowe calls discharge planning rounds.

"When we’re working on some of the quality improvement teams in the hospital, the outcomes managers are usually the facilitators of those teams, but the case managers are involved as well on a different level," Rowe says.

For more information, contact:

Michael Newell, RN, MSN, CCM, Managed Care Consultants, Merchantville, NJ. Telephone: (609) 665-8555.

Carmela Hartline, MS, RNC, director of disease management services, Grant/Riverside Methodist Hospitals, 111 South Grant Ave., Columbus, OH 43215. (614) 566-9310.

Connie Rowe, RN, CPHQ, director of quality, utilization and risk management; Carol Butler, RN, CCRN, outcomes manager for trauma, neuro, and ortho, Enloe Hospital, Chico, CA. Telephone: (530) 891-7339.

Judy Homa-Lowry, RN, MS, CPHQ, president, Homa-Lowry Healthcare Consulting, 7245 Provincial Court, Suite 100, Canton, MI 48187. Telephone: (734) 459-9333.