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Three months ago, when Ann Marie Distasio, RN, BSN, MSA, began working at Memorial-Hermann Memorial City Hospital in Houston, she could sense real fear among the social workers in her case management department. They were worried about job security and what their roles were within the department. "I think that as the clinical models for case management have evolved and become more common in hospitals, the older, more traditional social work role was being threatened, in the view of the social workers," says Distasio, director of case management services at Memorial-Hermann.
But in fact, she says emphatically, case management clearly positions social workers as vital members of the care team. The Memorial-Hermann case management model, "gives the most support ever seen in hospitals to the very absolute nature of social work — that is, working with people to help them adjust to changes that will occur due to their medical or surgical condition," she explains.
Memorial-Hermann recently has implemented a new case management model that its parent organization is launching across all of its 12 hospitals in Southeast Texas. "It’s a very progressive case management model," says Distasio. "It includes all the departments that have an effect on outcomes. Our department includes infection control and performance improvement, and there are very strong liaisons with risk management and quality, and of course, nursing and social services. We even include pastoral services as part of the multidisciplinary team."
Sharing case management duties works, says Toni Cesta, PhD, RN, director of case management at Saint Vincents Hospital in New York City. For the past two years, her facility has been using a dyad model of case management services, in which nurses and social workers perform definitive functions within the department and work together to manage patients. "It’s been working quite well. It really uses the professionals where their expertise lies, and to me, that just makes good sense," Cesta says.
Using the dyad model, Cesta’s case managers are RNs who work with social workers to help patients who meet certain high-risk criteria that the department has identified. "The functions are split up for different clinical areas: medical-surgical, maternal-child, HIV practice, the emergency department, etc." she says. "By having the prospective referral criteria, we’re able to deploy the social worker more quickly and to the right patients."
The objective is that with improved clinical pathways and reduced length of stay, not every patient will require social services or extended clinical care, Cesta explains. (For an example of referral guidelines, see "CM model makes good use of team members' talents," in this issue.)
Distasio’s facility uses a similar model that includes a series of collaborative meetings about each patient. "Once a week, there is a critical care team conference," that includes the nutritionist, the pharmacist, the chaplain, a respiratory therapist, and a physical therapist, she says. During the 45-minute conference, problematic patients are identified — those the team anticipates are headed for longer-than-normal stays. Distasio says this meeting alone is very useful. "I was overwhelmed when I started working here at how efficient this approach is."
In addition to meetings, the case management department at Memorial-Hermann completes a daily review. The RN case manager begins by addressing every new admission in critical care. If the diagnosis hits the established risk screen, the case management team is called in, beginning with the APACHE system coordinator, who gathers the data. "We want all the clinical data, as objectively as possible, to be recorded right from the start," Distasio explains. "The next person we pull in is the social worker, to do a complete psychosocial assessment within 48 hours. At the least, contact within the first 24 hours is an absolute," even if a complete social services assessment can’t be completed due to other circumstances.
"My picture is that, in order to go somewhere [within the health system], there is a driver. The person sitting in that seat is the nurse case manager, and riding shotgun is the social worker. Without those two people, we cannot move forward," she says.
That daily team approach to managing patients also is in use at Vanderbilt University Medical Center’s case management department, which is led by Evelyn Koenig, MSW, director of the Nashville, TN, facility’s case management office. "Our philosophy is that every patient needs to be managed, but not every patient needs case management." To determine which ones do, Vanderbilt has a triad team: nurse case manager, social worker, and utilization manager (UM). If a case is psychosocially complex, the social worker picks it up and "drives" the management. "But they all discuss the patients every day, so even if the social worker is managing, the nurse and the UM still have input," she adds.
Koenig says one of the obvious deterrents to implementing case management models of this nature is the apparent cost. She notes that, because two disciplines are involved, it appears costly, but in fact, the cost savings that can be achieved more than offset the salary costs. "My bias is that any administration that . . . feels that one discipline or another is unnecessary is short-sighted. An optimal case management model makes use of various skills. Collaborative practice is what’s truly going to make a difference in health care," she emphasizes.
In fact, at Memorial-Hermann, the administration is watching to make sure the new case management model does not in any way stifle the social workers, Distasio says. "They’ve come right out and said that," she adds.
As for the social workers who are at Memorial-Hermann, Distasio says their fears have subsided somewhat under this case management model. She predicts that as case management moves more into the community — into ambulatory care facilities, long-term care, and other subacute areas — social workers will experience a kind of renewal within case management. Social services skills are specialized.
"When you think of the issues confronting the population in our country, who could best serve that but a social worker? RNs are not trained in how to deal with dysfunctional families; that is not our expertise. The sensitivity for the expertise in social workers needs to be developed among nurses," she adds. "We understand their fear," Distasio says, but there’s really no need for it. "Will the fears ever be eliminated? Maybe not. But as the case management model in this company grows and expands into community care, I have a sneaking suspicion that our social workers will have no fear. They will see a rise in their esteem in the medical community. The bottom line is, case management cannot be done without them."
[For more information, contact:
Toni Cesta, PhD, RN, FAAN, Director of Case Management, Saint Vincents Hospital and Medical Center, New York City. Telephone: (212) 604-7992.
Ann Marie Distasio, RN, BSN, MSA, Director of Case Management, Memorial Hermann Memorial City Hospital, 920 Frostwood, Houston, TX 77024. Telephone: (713) 932-3572.
Evelyn Koenig, MSW, Director, Office of Case Management, Vanderbilt University Medical Center, 1161 21st Avenue S., Nashville, TN 37232. Telephone: (615) 343-6035.]