Case manager-physician collaboration essential for good patient care

Effective communication ensures a good working relationship

When it comes to talking with physicians about documentation or admissions criteria, it's often not what you say but how you say it that helps you get an answer.

Consider this: Which would you rather hear?

"You can't admit Mrs. Jones. She doesn't meet admission criteria."

Or, "I see you're admitting Mrs. Jones. Do you think she could go home if we arrange for home health services?"

Case managers must develop effective communication skills so they don't approach physicians in a way that suggests they are telling the doctors how to practice, says Jane Reed, RN, CCM, director of care management at Berkshire Medical Center in Pittsfield, MA.

"You'll get further if you work collaboratively with the physician. For example, ask the physician's opinion regarding what is going on with his or her patient, rather than telling them what they have to do. Otherwise, they may feel like they're being strong-armed, and no one likes that," adds Doris Imperati, BSN, MHSA, CCM, managing consultant for Navigant Consulting, a consulting firm with headquarters in Chicago.

A former case manager and case management director, Imperati works with hospitals for six months at a time, helping staff implement clinical documentation improvement programs and working side by side with the clinical documentation specialists as a colleague and mentor until they achieve the skills they need to work independently.

Rather than telling a physician a patient has met his length of stay and has to be discharged, ask, "Could you help me understand why you're keeping the patient here so I can communicate relevant clinical information to his insurance company?" she advises.

"The physician may have insight into the case that others do not, such as knowing that the patient isn't clinically ready for discharge or that there's a sick family member at home, or something else that may not be indicated in the chart," she says.

Keep in mind that physicians are concerned about caring for their patients and don't understand the twists and nuances of what each payer covers and doesn't cover, Reed suggests.

"Each patient's care has to be tailored to that patient's needs and the physicians know their patients. Case managers have to listen to what the physicians are saying when we query them. We have to be conscientious about cost but we also must do what's best for the patient," she explains.

"Case managers and utilization review nurses are hired because they are competent and confident and are effective because they take initiative, but sometimes they need to be cautioned about coming across as arrogant or condescending to the physician," says Steve Blau, MBA, MSW, LCSW-C, director of case management for Good Samaritan Hospital in Baltimore.

Good Samaritan Hospital began a program to improve collaboration with physicians five years ago. "We knew we couldn't control physician behavior but we could change ours. Some of the things we were doing were sabotaging our outcomes, by not being prepared or not having complete information when we called the physicians," he says.

The case management team started by determining what kind of relationship it wanted to develop with the medical staff, by identifying goals, and by defining what would determine that that improvement had occurred.

"We had to look at what we could do so physicians' experience with us would be positive. We wanted them to see us as being helpful and helping them achieve their outcomes," Blau says.

The case management team and the physician advisors attended quarterly staff meetings and department meetings and told the physicians their goals and what they were doing to meet them, asking them for help in achieving the goals.

"We're pushing them to think about organizing their day around what we see as priorities. They may not like that but we want to them to see us as being engaged in helping them achieve their outcomes," Blau says.

Getting physicians to listen often just involves using basic communication skills, Peter Moran, RN, C, BSN, MS, CCM, points out. Moran, a case manager at Massachusetts General Hospital, is the first hospital-based staff case manager to serve as president of the Case Management Society of America (CMSA).

"If physicians feel that case managers are there to assist them, they're more apt to respond. A lot of time, it's a matter of showing physicians that you can help them deal with a difficult case, rather than that you're telling them what to do," he adds.

If you feel a patient is ready to go home and the physician disagrees, ask if there is something you can do to address his or her concerns, such as sending the patient home and having a nurse see him or her the next day, Moran suggests.

Hospital-based case managers should get to know the physicians with whom they work and figure out the best way to communicate with them on an individual basis, Moran advises. Don't expect to come up with a one-size-fits-all strategy, he adds.

In some instances, the physician may prefer for you to talk to the nurse practitioner or physician assistant on his or her team. Some prefer e-mails; others prefer to set up a time to speak with you by telephone.

Once you get to know the doctors, understand what makes them tick and use that to build a relationship with both personal as well as professional aspects. Ask to see a picture of their new baby or where they went on vacation, Imperati suggests.

"Talk to the doctors when you see them on the floor. Take two minutes to build a relationship and let them know that you're not just going to be a nag but that you care about them as a person," she says.

When Imperati approaches physicians she doesn't know, she introduces herself, explains what her role is, tells them the name of the patient about whom she's inquiring and asks whether the patient still is in the hospital or discharged, and then asks for a few minutes of their time.

Recognize what else is going on with physicians when you talk to them, what type of mood they are in, if they appear rushed, if they are focused on a critical patient and then approach them accordingly, Imperati suggests.

"They may have a patient crashing or a backlog of calls to make and you're asking them to drop everything and talk to them," she points out. "Respect them and let them know that you recognize that you're interrupting their important work to do your work. If the physician seems to be pressed for time, offer to talk at a time when it would be more convenient for them," she adds.

Write out a script of what you're going to say ahead of time so you won't ramble, and aim for a straightforward discussion, not a fragmented conversation, Blau advises.

At Good Samaritan Hospital, the case managers consider what they are going to ask or say to the physician and may even practice with the physician advisor before calling the physician.

"Case managers need to think about their word choice and how they approach the physician," Blau says.

To keep her communication with physicians focused and on target, Imperati jots down a few phrases before approaching the physician, including which patient she's calling about, why she's calling, what the issue is, what she expects the doctor to do about it, and how quickly she needs the physician's intervention to occur.

If it's a telephone conversation and she needs the physician to change documentation in the chart, Imperati asks where and when the doctor wants to meet to resolve the issue.

"I keep it short. They don't want to spend time with me. They want to spend it with their patients and families," she says.

Sometimes the implication of what a physician documents in the chart is clear to the residents, the nurses, and the case managers, but it's not always clear in terms of language that can be coded, Imperati points out.

When CMs see a problem

"Nurses and case managers can look at the abnormal laboratory values documented in the progress notes and know that the patient is in acute renal failure but nowhere is 'acute renal failure' written on the chart. When I speak with a doctor I say, 'The BUN is elevated and the creatinine is elevated. Do you think the patient is in acute or chronic renal failure or is there some other condition causing these abnormal lab values?' I let them know that they're the experts and it's their patient," she says.

Imperati worked with a surgeon who frequently wrote "cherry red urine" on the chart and resisted writing "hematuria."

"We can't code 'cherry red urine,' but it gives a vivid picture of what is going on with the patient. 'Hematuria' doesn't indicate if the urine is dark red or clear with flecks of blood, but it has to be worded that way on the chart or we can't code it," Imperati says.

She explained to the physician that her job was to interpret what the doctors document into a language that the coders could code. The physician agreed to write "cherry red urine — hematuria" on the chart.

Many physicians don't realize that a patient must meet admission criteria specific for each condition as outlined in a reference book and that the patient should not be admitted unless those criteria have been met, Imperati says.

Meeting admission criteria

"They don't want to read the book, but it is sometimes helpful to open it to the page and ask if they see anything that you can use to show that the patient meets admission criteria," she says.

When it comes to documentation issues, pull out a resource book and show the physician how documentation can change things, she adds.

For instance, show him or her that without the complication/comorbidity (CC) the length of stay should be 3.2 days but when a CC is documented it allows the patient to stay for 4.8 days.

When inpatient criteria aren't met

When patients don't meet inpatient criteria, Moran reviews the available information, and then speaks with the patient and family to see what happened that brought them to the emergency department.

"I then share with the physicians what I learned and ask if there is a reason they are admitting the patient. I ask if they think the patient's needs might be met in a lesser level of care. It is my experience that if I can come up with a reasonable alternative to admission, physicians will listen as long as their concerns are addressed," Moran says.

When she was a case management director, Imperati spent five minutes during every physician staff meeting to educate the physicians on admission criteria, transfer criteria, community resources that patients could access rather than being admitted, and other issues that case managers encounter.

"Now that we have switched to the new MS-DRG system for reimbursement, I am spending a lot of time getting physicians up to speed on the new system. I go to the physician meetings, the specialty meetings, or drop by the physician offices and spend a few minutes giving them little snippets of information," she says.