Point out problems, then let go of them

Don't feel like you own the issue

It's frustrating when you point out that a patient doesn't meet acute care criteria or that documentation in a chart is not complete and nothing happens, even if you take it to your physician advisor.

Don't take it to heart. Move on to the next case and hope it turns out better, advises Peter Moran, RN, C, BSN, MS, CCM, emergency department case manager at Massachusetts General Hospital and president of the Case Management Society of America.

"I don't keep focusing on these cases. If I lose, it's not the end of the world. I look at it as making progress toward the next one," he says.

Start with the positive

At Good Samaritan Hospital, Steve Blau, MBA, MSW, LCSW-C, starts off every case management department meeting and every huddle with a success story to remind the staff of collaborative efforts that do work. Blau is director of case management for the Baltimore-based hospital.

Examples include when a physician came back to the hospital to write a discharge order or stepped up and worked with the case manager to expedite an appeal.

"Case managers and utilization review nurses have the job of identifying problems. If they do that long enough, they start to think nothing is going well and it wears on people over time. If a case manager is having a frustrating day, it's nice to hear that things do go right," Blau says.

The case managers write thank-you notes to physicians, nurses, therapists, and leaders who have been helpful in documentation or throughput issues.

Don't take full blame

Case managers get frustrated but they must understand that there comes a point when they have done all that they can do, Moran says.

"We don't own full responsibility for length of stay or patient admissions. We're responsible for reviewing information, trying to influence practice patterns, problem solving collecting data, and bringing problems to the attention of the administration. Once they have the information, it's out of our hands," Moran says.

Case managers are sometimes all too eager to take on full responsibility by applying admission criteria and saying the patient can or can't be admitted, Moran points out. "We're part of the team. We raise the questions, get the data, and when we bring it to the physician advisor, then it's their responsibility," Moran says.

Remember that admission criteria aren't necessarily black and white. "Guidelines look at severity of illness, intensity of services, but it is important to remember all of them also have a discharge criteria screen and one of the criteria looks at whether the patient is safe at discharge," Moran says.

When Moran completes an assessment on a patient in the emergency department who does not meet criteria, he contacts the physician, asks what his or her concerns are and how they can work together to resolve the issue.

"I go to the physician advisor when I can't get answers and I am at the point when there's nothing more I can do. If the physician advisor gets involved, it's great. If not, that's their decision and I let it go," he says.

Document clearly what is going on, Moran advises. For instance, you may think the patient needs a skilled level of care but can't get insurance authorization until Monday or you may not be able to find an appropriate bed.

Document all the options you explored, such as there were family members who could take the patient home, so it doesn't appear that someone who didn't meet criteria was admitted and nothing was done to try and avoid the admission, Moran says.