DorlandHealth

In this edition of Ask the Expert, Editor in Chief Anne Llewellyn sits down with Karen Zander, the principal and co-owner of The Center for Case Management, to talk about the viability of case management departments within a hospital setting.

Q: How can one defend the impact of a case management department when job cuts loom? Consider, for instance, a situation in which there are both full-time equivalent (FTE) nurses and FTE social workers responsible for utilization review, discharge planning, documentation improvement, and the collection of core measures.

A: If you can’t trace the FTEs to key goals, case management will be seen by some in administration as a very expensive department of clinicians (often at the top of the pay scale due to seniority) that conducts random, repetitive processes unrelated to the hospital’s margin and mission. Hospitals that are thriving today are ones that expect results and hold vice presidents and their department directors accountable for achieving them.

Executive teams can be “hard” on case management departments because a lot of results are expected. The good news is that they will almost always protect the service (and the FTEs) if they understand that it is consistently showing success (even if they don’t understand the detailed processes of how success is achieved). If you are a director, you are an essential translator between the frontline, bedside staff and the vice presidents. You must connect case management services directly to at least one, if not all, of the following results:

1. Creating new revenue, i.e., clinical documentation improvement.
2. Protecting deserved revenue, such as ensuring only minimal dollars lost through denials for medical necessity; preventing CMS’s RAC (recovery audit contractor program) from taking away revenue already collected due to inaccurate leveling of patients as inpatient vs. observation.
3. Ensuring tangible quality goals, such as drastically improving patient satisfaction in key questions (not just collecting core measures) or decreasing the readmission rate because of more accurate discharge planning.
4. Being indispensable to key physicians and nursing units and nurse managers, i.e., taking the crisis out of discharge planning by being proactive; running care coordination rounds; and helping hospitalists be more efficient.
5. Preventing surprise visits from Medicare by ensuring compliance with patient choice, CMS’s Important Message, and other regulations. So the real question is, How can I show that the FTEs and responsibilities of the department are achieving strategic, measurable goals? And the answer is not how hard everyone works at all their responsibilities, or to benchmark other departments, but to constantly negotiate the ever-expanding potential of case management to see if these targets are wanted and supported.

Q: What are some immediate actions to be taken?

A: The following constitute effective immediate actions:

• Use the vice-president to whom you report to develop/connect a case management dashboard to the hospital’s dashboard.
• Find a resource person within the organization or health system that can help you find and quantify data, such as calculating the base rate used in other formulas.
• If the hospital does not have a dash board, develop a departmental dashboard anyway.

Q: What other steps might one consider?

A: Further actions include:

• A hospital that is large enough should have an ED case manager during prime time to 1) begin leveling patients on the front end (which will help you avoid the feared RAC) and 2) refer or discharge patients to home care, SNF, etc., that do not require an acute care bed.
• Begin to create more of a presence clinically by moving staff into the care coordination function of case management. UR, core measures and CDIP tend to be invisible processes without a lot of meaning to nurses and physicians. When case management nurses and social workers start to become leaders of the treatment team to fill in the void caused by a lack of continuity of care, they become visible. Therefore, the RNs and SWs in case management have to know and communicate the full story about the patients and families from admission to discharge.
• Establish a work process in which case managers gain credibility because they actually meet with every patient to assess them, at least once during the stay. Ideally, the work ethic should be “every chart, every patient, every day.”
• Find and teach leverage points by which case management staff can become more knowledgeable and efficient. For example, they should lead care coordination rounds daily.

Karen Zander, RN, MS, CMAC, FAAN, is the principal and co-owner of The Center for Case Management Inc. She has pioneered work with clinical care management and CareMap® systems. [ This e-mail address is being protected from spambots. You need JavaScript enabled to view it ]