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The role of case managers varies considerably from hospital to hospital. In some facilities, case managers spend much of their time searching for outliers in terms of length of stay and resource utilization.
The Ohio State University (OSU) Health System in Columbus has opted for a markedly different strategy. "A typical case manager probably would not work well here," explains Gail Marsh, administrator for performance review and analysis. Instead, OSU assigns every patient a patient care resource manager (PCRM) who is responsible for coordinating that patient’s hospitalization from pre-admission planning through post-discharge follow-up.
"Every patient, whether they are at the hospital one day or 35 days, has a PCRM," says Marsh. "[PCRMs] are somewhat of a patient advocate as well." The majority are nurses who act as a cross between a physician assistant and a case manager, she explains. In addition, they are responsible for fiscal accountability, quality monitoring, and patient facilitation.
Most case managers work for the hospital, and their job is to manage patients for the hospital through their system, notes Marsh. Likewise, most hospitals hire case managers and then have them report to nursing or another department.
While that model may achieve some degree of physician buy-in, Marsh says, OSU makes physicians responsible for managing the patient efficiently through the system. PCRMs are aligned with physicians to help them accomplish that. Although half of the PCRM’s salary is paid by the physician and half is paid by OSU, Marsh says, PCRMs take their direction entirely from physicians.
The decision to establish this system may have been influenced by the fact that OSU is an academic facility, says Marsh. Regardless of the motivation, it has proven very effective. According to Marsh, since the first PCRM was hired seven years ago, hospital length of stay has been dramatically reduced in a number of clinical areas, insurance denials have fallen, and patient satisfaction has increased. OSU’s system has been emulated by numerous institutions, including Duke University in Durham, NC, and more than two dozen facilities have visited OSU to see firsthand how the system functions.
PCRMs also have significantly expanded patient education, established working relationships with other care service providers, and contributed to outcomes research and the development of clinical practice guidelines.
Also central to OSU’s program are diagnosis-specific value enhancement teams (VETs), which act as interdisciplinary, action-oriented teams responsible for analyzing areas for clinical improvement and developing appropriate programming to support delivery of care.
VETs are specific to clinical service lines and are made up of physicians and nurses. They are complemented by representatives from support areas, such as radiology, laboratory, finance, and managed care. All four types of outcome measures — clinical, functional, cost, and patient satisfaction — are evaluated in a single setting by caregivers. Examples of some of the VETs at OSU include cardiovascular, pregnancy, neuroscience/rehabilitation, cancer care, and nephrology/abdominal organ transplant.
According to Marsh, PCRMs act as "facilitators" for the VETs. "A VET is designed to bring together all the people that take care of a certain type of patient population and improve that care," she explains. "The PCRM’s role is to facilitate all those people coming together and act as the key resource and key clinician to improve care."
While quality improvement coordinators examine data across all patients, PCRMs implement the quality standards developed. "PCRMs are the ones who operationalize that for us on a daily basis, patient by patient," says Marsh. "That makes them key contributors to these VET teams because they know what is going on every day on our patient care unit."
OSU’s cardiology program is a case in point. "We have three different services and three PCRMs that cover each service," reports Terry Fricker, RN, cluster leader for cardiology who oversees that area. OSU also includes representatives from each team along with a resident and two interns.
The team conducts rounds with physicians every day and assists in developing the discharge plan, Fricker says. PCRMs also coordinate with each other, she reports. For example, a patient in the cancer hospital who suffered a heart attack might be transferred to the cardiology department while in the acute phase and then transferred back.
"Even after we transfer them back, I keep in contact with that particular PCRM so that the cardiology aspect receives attention," Fricker says. "We all work closely to share information and share resources. In practice, it works very well." Some interns exposed to the program early in their training don’t understand how they could function without it, she says.
One intern reported coming from a hospital that expected her to set up the extended care placement, even though she never learned that in medical school. "This program eliminates that type of problem and gives them the support they need," says Fricker.