Critical Path Network

Work as a team to meet needs of all your patients

Case managers should look beyond assigned unit

Hospital case management should be a team approach, with everyone on the team looking at what needs to be done for the patients and making sure it gets done, says Judith Martin, RN, CCM, director of medical management for Regional Medical Center, a division of Trover Foundation, a nonprofit health care organization in Madisonville, KY. "Case managers can’t have the attitude that they are responsible only for their assigned unit. The entire team has to look at creative ways to meet the needs of the entire house and must be willing to support one another in meeting those needs," she says.

At Regional Medical Center, case managers and social workers work as a team to meet the needs of hospitalized patients. The hospital, which serves the Western Kentucky area, has an average daily census of 150 to 160 patients. Staff are assigned by unit, with some members rotating between units and filling in when needed.

The case managers handle utilization review, case management, and some discharge planning with the support of social work. Social workers take the lead on the more time-consuming discharge planning cases and those where patients and families may have psychosocial needs.

The members of the case management team come in as early as 6:15 a.m. and stay as late as 5:30 p.m. They are on call weekends and holidays. "It is advantageous to see the physicians as they make their early morning rounds, and on a couple of units, we’ve found it just as advantageous to attend the morning nursing shift reports," Martin says.

"Case management is not accomplished by just one department. Effective case management comes through the input and collaboration of the entire team." Some units, such as a critical care unit, may or may not require eight hours of a case manager’s day. Instead of having down time, those case managers can help on other units with simple tasks that they can complete and easily hand off if they are needed back on their own units, she says.

For instance, the hospital’s three medical-surgical units have a census of 28 to 32 per day, which is too much for one case manager to handle on his or her own because of the acuity of patients. The units are covered by 3.3 case management full-time equivalents (FTEs) and 1.7 social worker FTEs. The social workers are shared by the three units.

Each med-surg unit has a full-time case manager with assistance provided by the critical care case manager who helps with more straightforward functions such as utilization review, evaluations for core measures, or Medicare issues. "She’s a great liaison because many patients on these units just left the critical care unit the day before," Martin says.

The case managers who float to other departments do so when needed with general expectations as to what is to be accomplished, she says.

For instance, in general, the critical care case manager works on her unit from 8 a.m. to sometime between noon and 1 p.m., then helps out on the med-surg units. She participates in the informal med-surg team meetings, held right after lunch, where the team discusses what is left to do on the unit and divides the remaining workload. The med-surg team also meets at 8:30 a.m. to discuss what needs to be done that day.

"This arrangement allows our case managers who are unit based to work with the social worker to identify who needs case management services the most and who needs the services of a social worker the most," she says.

In cases with complex medical issues, the case manager and social worker partner to make sure the patient has everything he or she needs.

For example, if a young person comes in for abdominal surgery and the surgeon finds meta-static cancer, that clinical course will require some level of case management. The patient and family also will begin dealing with psychosocial and acceptance issues, which require the help of a social worker. Therefore, both disciplines should be involved in the patient’s care.

"When someone has a complex medical course, they need a nurse on board, but that does not negate the need for social work. There are many psychosocial issues that come with these kinds of medical diagnoses," she adds.

In other units, the case management and social worker staff are assigned according to the anticipated acuity of the patients. For instance, one RN case manager is assigned to the labor and delivery unit, postpartum/newborn unit, the neonatal intensive care unit (NICU), and the pediatric unit.

"Those populations are more predictable and this case manager can usually take on a higher caseload than those on other units. Our OB/GYN population is fairly predictable from a case management standpoint, and the acuity level in pediatrics and the NICU is fairly consistent," she says.

One full-time RN case manager and one of the social workers assigned primarily to the med/surg unit cover the transitional care unit and the acute rehabilitation unit. This equates to 1.3 worked FTEs. Between the two units, post-acute caseload typically is 20 to 25 but has risen to 27 to 29 in recent months.

"These patients have more predictable needs. They are not so acute when they come to the unit, and they already have a plan of care established. The case manager does a lot of family interaction, discharge planning, and working with the interdisciplinary team," she says.

The hospital has 0.8 of a social work FTE whose time is split between critical care and the NICU, two units where there are likely to be intensive patient needs. This social worker also serves the OB/GYN and pediatrics units.

The CM team looks at ways to facilitate care in units that are high volume and have a high turnover. For instance, when a patient is scheduled for total joint replacement surgery, the case manager starts the discharge planning when the patient comes in for his or her preadmission visit.

The case managers meet the patient and fill out the discharge assessment during the preadmission visit, finding out what resources the patient has at home and what support system is available, and assessing for insurance issues that may arise during the stay when they prepare the patient for discharge.

"The case managers will deal with the medical issues that may arise when the patient is in the hospital, but starting the discharge planning before admission certainly streamlined the process and enhanced the level of patient participation in planning for their care," she says.

The case management team supervisor covers the entire hospital, filling in where needed because of increased volume or acuity, giving support and direction when issues arise, lending support to outpatient areas, and fulfilling leadership responsibilities.

The team members communicate with her whenever they need assistance. For instance, if the critical care case manager is involved in a lengthy family-physician session, the team supervisor finds someone to help with his or her regular duties or handles the task herself. Team members always are available by beeper.

The team supervisor and the social worker who divides her time between critical care and the NICU are on call to help in the emergency department when issues arise.

"They have assisted in many ways. Some assistance has been given, in collaboration with the primary care physician, arranging home health for patients being discharged through the emergency department, finding available beds in psychiatric facilities, or making referrals to chemical dependency treatment centers, and supporting the families of trauma victims and the staff who are caring for them," Martin says.