Do your homework before submitting a redesign plan
Do your homework before submitting a redesign plan
Show how reorganization will help bottom line
The most challenging part of redesigning a care management model is developing data and statistics to show the hospital administration that the extra expenditures will have a positive impact on the hospital’s bottom line, notes Catherine Korn, RN, MS, CRNP, vice president of nursing at Southern Ocean County Hospital in Manahawkin, NJ. The 117-bed hospital piloted a redesigned integrated case management model in the telemetry unit in May, gradually introducing it to other units over the course of the summer.
Joseph P. Coyle, president and chief executive officer, is fully behind the changes. When Korn came on board, one of her goals was to create a case management department, combining the independent functions of the utilization review nurses and the social workers.
Nevertheless, Korn and Marilyn Butler, RN, MS, CCM, director of case management, spent considerable time compiling information to show that the increase in expenditures the plan would entail would pay off in the long run.
"You have to be able to prove, in language that they understand, that the expense of implementing the plan will make the hospital money in the long run by reducing the length of stay and denials," Korn explains.
Southern Ocean County is one of the fastest growing areas in the state. The hospital frequently operates at capacity, with patients waiting in the emergency department (ED) because there are no beds. About 80% of patients are admitted through the ED, and a large percentage of patients are discharged back to nursing homes.
Korn worked with Rick Hand, chief financial officer, to identify the metrics he would use to measure the success of the redesigned department.
Among the measurements they identified were denial rate, length of stay, and patient satisfaction scores. Korn and Butler developed a presentation to prove that they could meet these goals. "For instance, Rick gave us a target denial rate of 5%. We looked at whether it would be possible to reach that and researched other facilities and found out that it was a reasonable denial rate. We applied a dollar amount to how much the reduction in denials would save the hospital," Korn explains.
Korn and Butler compiled data on other statistics that could be affected by an increase in efficiency, such as getting patients from the ED to a bed, cutting the hours the hospital is on ED divert, and delaying construction of a new medical-surgical unit. They are in the process of developing a report card that Korn will give to senior leadership once a month, comparing the length of stay, the denial rate, and patient satisfaction scores.
"We are focusing on the financial viability of the proposal to translate what this program means and where the administration could expect to see an impact," Korn notes. When she assumed her position in November 2004, the hospital had utilization review nurses and social workers, who functioned independently.
Korn hired Toni Cesta, PhD, RN, FAAN, vice president for administration at North Shore-Long Island Jewish Health System in Great Neck, NY, as a consultant to assess the hospital’s situation and recommend a blueprint for developing the case management department.
Korn created a director of case management position and hired Butler to fill the position and work with her on creating the new department.
"We talked a lot about finance, but we didn’t lose sight of a focus on the quality of patient care, getting the patient to the right place at the right time, and helping families with the transition. Case managers can really improve quality," she says.
Korn and Butler decided to keep the incumbent nursing staff who were handling utilization review and teach them case management, while hiring additional staff.
"We had a loyal staff of utilization review nurses who worked with us through the transition. We educated them about the case management model. Since we started, all of them have become certified case managers," Butler says.
The new staff have case management experience and are partnering with the incumbent nurses. The two groups are cross-training each other on elements of case management and how the hospital works.
Butler chose a fully integrated case management model with two case managers and one social worker based on each unit. The team typically covers 32 beds. Case managers see 100% of patients and work as a team with the social workers.
They assess patients within 24 hours of admission, handle utilization management, and handle referrals for home care, dialysis, hospice, and other clinical needs of the patients.
They make rounds each day with the staff nurses and the physician advisor, concentrating on length-of-stay issues, making sure each patient meets medical necessity criteria, and identifying any barriers to discharge, such as pending test results.
When necessary, the medical director will get in touch with the attending physician to make sure the patients are discharged in a timely manner.
The social workers provide counseling and support for patients and families, assist the case manager in identifying any community resources the patient may need, and handle post-acute placements in nursing homes or subacute units.
When the plan was implemented, case managers and social workers covered the hospital Monday through Friday, beginning weekend duty in September. Because 80% of hospital admissions come through the ED, plans call for putting a case manager and a social worker in the ED 12 hours a day, five days a week. The hospital has allocated an additional 1.5 RN full-time equivalents (FTEs) and five social work FTEs to cover the ED.
There was some initial resistance to the new model among the staff nurses, who now give positive feedback about working with the case managers, Korn says. For example, a weekend charge nurse reported that discharging four patients back to nursing homes on a Saturday went smoothly because the case manager had everything in place before leaving on Friday. In the past, the weekend charge nurse would have had to handle all of the details of the discharge.
"The social workers and case managers have been able to anticipate discharges that will occur on the weekends so that patients are not staying in the hospital unnecessarily," Butler adds.
(For more information, contact:
- Marilyn Butler,RN, MS, CCM, Director, Case Management, Southern Ocean County Hospital, Manahawkin, NJ. Web site: [email protected].)
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