Case Management Insider Back to Basics: A Day in the Life of a Hospital Case Manager Part 1
Toni Cesta, PhD, RN, FAAN, Senior Vice President, Lutheran Medical Center, Brooklyn, NY
The role of the hospital case manager has taken many twists and turns over the past two decades. Case management started out as a sectioned-off role of utilization review without any relationship to the direct care providers or interdisciplinary care team. From those early roots we have evolved to departments that incorporate utilization management, discharge planning, patient flow, documentation improvement, transitions in care, and coordination of care. You can probably think of even more roles that we perform, or you may do different things in your specific department. Terms like coordination of care, transitions in care and patient navigation have become part of the lexicon of health care as we move through the beginnings of the Affordable Care Act and beyond. These terms have been common language in our field, but are now embraced by the wider spectrum of payers and health care providers at large. While exciting, we must ensure that we maintain a seat at the health care table and that our voice continues to be heard. We continue to carry the burden of shaking off the old perceptions of what case management "was," while helping others to embrace what we are "becoming."
As our roles and functions have evolved, some of our departments have remained staffed as if they were still departments of utilization review. Case management departments responded to the ever increasing requirements of health care, but without the staffing ratios to support the volume of work. This is why I decided to write about a "day in the life of a case manager" this month. You are probably one of the many case managers who struggles to complete your workload every day. You probably feel overwhelmed many days, or maybe most days. While appropriate staffing ratios are fundamentally important, your hospital may not be adding additional staff at this time. Despite the amount of work you must complete, you enjoy your job and want to do the best that you can every day for your hospital and for your patients. With that in mind, this month we will review some of the ways in which you can organize your work to help you be more effective with the time you have. First, we will also review the case management process steps.
The Case Management Process Steps
Each step combines elements of both utilization management and discharge planning, as well as patient flow and transitional planning. It is important to understand that these steps are not linear. You may find yourself circling back on them and/or repeating the process. You may even need to occasionally skip a step or the step may not be necessary to the particular situation. These steps are "guidelines" and are only meant to be used to give you direction and focus.
Step 1: Case Finding/Screening and Intake
On admission, or after the case has been assigned to you, you must immediately begin the screening and intake process. Please note that this first step is critical to the entire case management process. If you do not follow every patient, then you must screen the patient for case management needs and follow him or her according to the criteria that your hospital uses for following patients. Then you can begin the case management admission process.
If you follow every patient, then you can begin the case management admission process. In order to admit the patient, you should have a standard admission assessment tool that you use to collect the data that you need to begin case managing the patient. If you do not have a standard tool, then you should document your findings in the progress notes section of the medical record. You should try to collect the same information each time you admit a patient, so this is why a standard tool is helpful. However, if you can't do that, then a consistent format for notes can work well too. Either way, the assessment should be placed in the medical record on the day of admission.
Once you have completed you admission assessment, you should complete your initial clinical review on the patient. The purpose of this initial review is to determine if the patient meets acute care criteria and has been appropriately admitted to the hospital. In other words, is the patient in the right level of care? It is important to make this determination as quickly as possible. If you do this immediately on admission, and the patient does not meet criteria, then you can apply Condition Code 44 to the patient if he or she is a Medicare recipient.
At the same time, you should be beginning your discharge planning. You should use the information you collect from the initial assessment to make a determination as to the discharge destination as best you can based on this initial information. It is understood that this initial destination may change as the patient progresses toward discharge. However, 70% of the time this initial discharge destination selection remains as the ultimate discharge destination. The Centers for Medicare & Medicaid Services (CMS) expects that an initial discharge destination be identified as soon after admission as possible.
Collect Data Once for Multiple Purposes
By obtaining the initial assessment on the day of admission, you can use the information you collect to do your clinical review and begin the discharge planning process at the same time. This is a time-saver and makes your work process more efficient!
Step 2: Assessment of Patient Needs
Once you have done your initial assessment as per above, you will need to synthesize the information and begin to identify the patient's needs while he or she is in the hospital and then for discharge, as mentioned above. As you begin this process, you will need to review the patient's financial status and insurance coverage so that you will be able to ensure that services they may need after discharge are available to them.
It is at this point that discharge planning conversations should also begin with the patient and the family. These initial conversations are important to the discharge planning process. In addition to insurance coverage, this is the point at which you should begin to talk to the family and assess their home environment as well as their ability to care for the patient at home. Even if the patient is going to sub-acute care after discharge, the home environment still needs to be reviewed as ultimately the patient will be going there.
Any plans, even initial ones, should be agreed upon with the patient's physician, the patient, and the family. By not skipping this step, you are more likely to have the cooperation of all parties at the time of discharge from the hospital.
Step 3: Identification of Actual and Potential Problems — Service Planning
By the time you reach step three in the case management process, you should have gathered enough information to begin to write a plan of action. This plan should include:
- the patient's inpatient plan of care;
- any barriers to achieving the outcomes of the plan of care;
- the items needed to meet the patient's post-discharge needs;
- services needed after discharge that require authorization;
- a set of goals that are agreed on by the patient and family as well as the physician for the hospital stay and beyond discharge.
By assessing the patient at the beginning of the hospital stay, you should have all the information you need to create a plan of action as described above. The plan is an important step in ensuring that each day that the patient is in the hospital is optimized so that there are no delays and no denials. It is also important in terms of managing the expected length of stay against the patient's achievement of the expected outcomes of care. As the patient progresses, the outcomes and/or length of stay may have to be adjusted to meet the changing needs of the patient. This may mean a longer length of stay, but it may also mean a shorter length of stay in some instances.
It is critical to reassess the patient on a daily basis and to continuously re-evaluate the plan of care. As described above, this will ensure that things are moving along in sync with the patient's actual response to treatment.
Step 4: Linking Patients to What They Need
Step four in the case management process encompasses several elements. It begins with the communication of the daily reviews with the third-party payers. From there, the case manager must obtain any necessary authorizations. These steps are designed to be sure that patients have what they need upon discharge.
However, there is another important piece to this step that takes place within the walls of the hospital. That has to do with coordination and facilitation of care. The case manager has an important role to play in terms of linking patients to what they need while in the hospital, and to be sure that the services required are delivered on a timely basis. You may think of this step as "patient flow,' or the movement of the patient through the acute-care continuum. As case managers, this step is just as important as the discharge planning process. It is the manner in which we ensure an appropriate length of stay, appropriate resource use and consumption and appropriate movement of the patient toward expected outcomes.
Patient flow also assists the hospital in being as efficient as it can be with its internal resources by identifying barriers to care, delays and other opportunities to optimize daily resources for the patient and the hospital.
By managing resource consumption and patient outcomes each and every day, length of stay targets are much more likely to be achieved.
Step 5: Implementation of Interdisciplinary Plan of Care
During the implementation of the interdisciplinary plan of care, the case manager should be watching for delays in service. These delays can result in increased length of stay and/or a denial of payment if your hospital has per diem contracts. The patient should be monitored each and every day against the expected outcomes for that hospital day. The plan of care should be adjusted if the patient's progress is slower or faster than expected. During each day, the patient's progress should be evaluated so that the patient can be moved to the next level of care in a timely manner. It is the case manager's responsibility to determine the patient's state of readiness and to optimize that as soon as it happens.
It is during this step that the case manager should also be exchanging clinical information with the appropriate post-discharge agencies or facilities, as appropriate. By managing the discharge planning process throughout the course of the hospital stay, you will reduce the likelihood of last-minute details or problems on the day of discharge. This is why discharge planning MUST be considered a "process," not a "destination."
It is also during this step that the case manager should be monitoring and re-evaluating the selected discharge destination. As you are in communication with the third party to obtain authorizations, you may want to consider a "dual discharge plan" for those patients whose discharge destination may not be as clear.
For example, you may not be able to determine on admission if your fractured-hip patients will be able to go home with physical therapy or will need to go to sub-acute rehabilitation. The decision to go to the higher level of care, sub-acute, will be dependent on the patient's response to physical therapy. If the patient has a good response, you should consider the lowest level of care appropriate to the patient depending on what the patient can tolerate. Because this type of decision can vary right up until the day of discharge, dual discharge planning can be used as a strategy to ensure that there is no delay on the day of discharge. Hopefully your insurance-based case manager will work with you to orchestrate these types of plans.
Step 6: Evaluation of Patient Care Outcomes / Monitoring the Delivery of Patient Care Services
As you move the patient toward discharge, you must continuously evaluate the patient's readiness for discharge based on his or her outcomes and response to treatment. As we discussed earlier, the case management process is not always linear, and you may find yourself circling back to specific steps in the process as you continuously move the patient toward discharge. This is to be expected and is appropriate.
At this point in the process you should have begun confirming the discharge destination with the patient and the family. As mentioned earlier, this discussion should begin almost upon admission so that the patient and family are in sync with the process as it moves along. Keeping them informed as you progress toward discharge will ensure a better outcome for all.
It is also critical to maintain communication with the patient's physician on a daily basis. The case manager and the physician must be coordinated in their approach to the discharge plan, too. You do not want the physician to say one thing to the patient and family while you are saying something else. This will surely sabotage the discharge plan. By working directly with the physician, all members of the team can communicate a standard message to the patient and family. Nothing will dissatisfy a patient more than having multiple providers giving him or her different messages.
At this point, you should have also obtained all necessary authorizations from the third party, if this is required. This will also ensure that there are no last-minute delays. If you had to do a dual discharge plan, as explained in step 5, then by step 6 you should be able to select which of the dual plans will meet the patient's post-discharge needs and begin to activate that plan.
If you maintain open lines of communication with the patient, the family, and the third-party payer, you will ensure that things happen as smoothly as possible. Of course, there are many things that can happen during the course of care, and things do change. However, if you are in constant communication and have a relationship with all parties involved, even necessary changes will be accepted more readily.
In this month's Case Management Insider we have begun to review the case management process. The process has a total of eight steps, and we have completed our review of six of them. Next month we will continue with the final two steps in the case management process and also discuss best practices for doing an admission assessment. We will also review a case study which should help you in applying the steps we have been reviewing!
Maintain open lines of communication throughout the entire discharge planning process to ensure smoother outcomes for you, the patient, family and physician.