Consider a new CM model to help your staff work more efficiently
Consider a new CM model to help your staff work more efficiently
Rising denials and longer lengths of stay are red flags
If your length of stay is above your expected target and your denial rate is rising, you might need to consider redesigning your case management department, suggests Toni Cesta, PhD, RN, FAAN, vice president for administration at North Shore-Long Island Jewish Health System in Great Neck, NY.
"When you are getting blamed for length of stay and an increase in denials, look at whether it’s because the staff aren’t doing their jobs or it’s because the model isn’t working. In many cases, the problem is due to lack of communication because case management, social work, and utilization management are in different departments, and no one knows what the others are doing," she says.
Other red flags that may indicate you need to change the way your department works include admission denials, poor patient satisfaction scores, failure to identify high-dollar cases early in the stay, a high readmission rate, and quality issues, Cesta adds.
"If physicians are unhappy because they go to the floor and can’t get what they need for patients, or if their patient has to stay in the emergency department and can’t get a bed, your case management system may need tweaking," she says.
In all of these cases, reorganization can work wonders to bring disparate entities together in an effective and efficient manner, Cesta notes.
Faced with $8 million a year in denials and an increasing number of high-risk, high-dollar cases, Children’s National Medical Center in Washington, DC, created a clinical resource department, which handles utilization management, case management, and social work. As a result, the hospital has experienced a 66% drop in denials and a 15% decrease in length of stay.
"Sometimes, directors of case management are so frustrated because they can’t meet their outcomes targets. It may be as simple as the fact that they don’t have enough staff," Cesta says.
To gain administration support for hiring more people, conduct a time-and-motion study on how much time it takes your staff to perform all the functions of their jobs.
"If you come up with 12 hours of work in an eight-hour day, that’s a sign you need more people," she explains.
Do your homework before embarking on a clinical redesign project, and be prepared to justify the changes and the expense to management, suggests Catherine Korn, RN, MS, CRNP, vice president of nursing at Southern Ocean County Hospital in Manahawkin, NJ.
"The most rigorous piece for me was developing a presentation for the senior leadership group that communicated our vision, how it would improve the quality and efficiency of patient care, as well as identify metrics that we could use going forward that would prove that what we are doing makes a difference," she says. For instance, the clinical redesign at her hospital called for hiring two additional RN case managers, an additional social worker, and a clerical person.
"Since this represented a significant investment in positions, we had to convince senior leadership that the case management program would not only improve the quality of patient care but also would prove to be cost-effective," Korn adds.
The model that will work best for you depends on your organization’s corporate culture and how the case management role fits into the hospital as a whole, Cesta says.
Before starting your re-engineering project, decide which role functions you want integrated and which you want separate. Decide what you want your staff to do and not do.
Look at the role of the nurse case manager vs. the role of the social worker and decide how you can best utilize the skill sets of each discipline.
If the social workers are doing things they aren’t equipped to do and the nurses are doing tasks that others could do, you’re not maximizing your resources, she says.
"Discharge planning nationally is moving in the direction of placing the nurse case manager in charge of the process, with the social worker as a collaborator in the process. Discharge planning is much more clinically complex today, and therefore, hospitals should consider using clinicians, such as nurse case managers to drive the process," Cesta adds.
Determine what kind of functions you can designate to your clerical staff to free up the case managers and social workers, and consider automating your case management documentation system to save your staff time and make them more efficient.
Whether you provide case management services for every patient or only for some also will drive the type of model you develop. Look at the pros and cons of several case management models before deciding which will work best for you.
In many traditional models, each member of the health care team focuses on a core activity. This is fragmented, expensive, and has the potential for overuse or underuse of resources, Cesta says. In a partially integrated model, case managers focus on two of the core activities. This is more efficient and more cost-effective but not as efficient and effective as a fully integrated model, she adds.
In an integrated model, all functions are performed by a single case manager, combining all previously disconnected functions. These include clinical coordination/facilitation, utilization management, transitional planning, variance tracking, and quality management.
The social worker in an integrative model works collaboratively with the RN case manager on high-risk cases; performs some functions of transitional planning such as nursing home placements, shelter placements, and guardianships; performs psychosocial interventions; and assesses patients with complex psychosocial problems. Other functions include providing emotional support and identifying barriers to a safe and timely discharge plan.
The collaborative practice model separates the business and clinical functions of case management into separate roles. In a collaborative practice model, there is a case manager, a utilization/ DRG manager, and a social worker. Case manager roles include risk screening, assessment and planning, coordination of care, resource utilization, and outcome management.
Case managers in this model partner actively with social workers to achieve results. The utilization/DRG manager works primarily with the business side of case management, handling medical necessity screening, authorization and certification, observation status compliance, DRG assurance, and denials management.
Proponents of the collaborative practice model, also called the triad model, suggest the model frees case managers from utilization management tasks and gives them more time to spend with their patients. "In my mind, it doesn’t go too far afield of traditional models that include utilization review nurses. It adds additional layers, and you don’t get the economies of scales that you have when one person does everything," Cesta says.
The clinical person who is managing the patient care process is the best person to talk to the insurance company because he or she already know what is going on with the patient, she adds.
"If we manage the patients well, make sure everything gets done, and handle discharge planning in a timely manner, the hospital will get paid. This puts patients first, rather than having finances as the first order of business." Case managers may be assigned by product line, unit, or physician, and each model has its pros and cons, Cesta says.
List the pros and cons before you choose
Before choosing a model for your case management department, list the pros and cons of each approach and see what works. Most hospital case management departments find that basing case managers on the unit works best, she notes.
"In a unit-based model, the case managers are more accessible to the staff, the physician, and the family. With a physician-based or disease-based model, you might have an influx of five case managers on the unit at the same time," says Marilyn Butler, RN, MS, CCM, director of case management at Southern Ocean County Hospital, who has 10 years experience as a case manager.
Space on the unit is at a premium, and having a crowded unit puts pressure on staff, she adds.
Case managers who are unit-based can carry a larger caseload because they aren’t spending their time going from unit to unit. Since they are a physical part of the unit, the staff or attending physicians know which case manager to contact when they need to, Cesta adds. When case managers are assigned by product line, the same case manager coordinates care for the patient throughout the hospital stay, giving continuity of care, she explains.
For instance, if a patient comes in for a cardiac catheterization and needs open heart surgery, the same case manager is with the patient throughout the whole process.
The downside to a unit-base model is patients don’t have continuity of care when they are transferred from one unit to another. That’s why Butler urges her staff to give a thorough report to the case managers and social workers on the receiving unit when a patient is transferred.
"What you lose in this model is the case manager’s availability on the nursing unit. They’re not physically present and not part of the staff. There is a lot of downtime if case managers see patients on different units," Cesta says.
Some hospitals have unit-based case managers who are generalists as well as disease-specific case managers who work with any patients with particular diagnoses. "It’s more expensive than the unit-based model, and nobody has an open checkbook any more," she adds.
Before considering a physician-alignment model, Cesta suggests that case management directors carefully weigh the pros and cons. "People think that if case managers have direct relationships with physicians, they can have a better impact on the length of stay. In reality, the physicians tend to get the case managers to fill in functions they would otherwise handle."
Aligning case managers with hospitalists is an idea worth testing, she says, but the arrangement poses a problem as to who manages the patients not assigned to hospitalists.
"If you align a case manager with a specific hospitalist, you won’t capture all the patients, and you’re getting away from the efficiency of having unit-based case managers," Cesta adds.
If your length of stay is above your expected target and your denial rate is rising, you might need to consider redesigning your case management department, suggests Toni Cesta, PhD, RN, FAAN, vice president for administration at North Shore-Long Island Jewish Health System in Great Neck, NY.Subscribe Now for Access
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