 High Intensity Escalation as Strategic Intervention
The practice of case management continues to evolve as our skills are honed and our tools become more refined. Health care reform will impose swift and dramatic changes in our practice by forcing us to improve our ability to predict the date of discharge and develop a discharge plan that is almost foolproof in avoiding readmissions. The emergence of nonacute care partnerships will create smooth and timely discharges, many of which will be considered “value” discharges. Those are the cases that require funding and should not be kept in the acute care setting when medically ready for discharge.
Changes that stem from health care reform require strategies that are sustainable and lead to effective discharges. Further, such strategies need to be formalized and structured to ensure that they are user-friendly, effective and transferable to all patient populations.
High intensity escalation is not a new concept to many skilled practitioners, who have used these strategies throughout their years of practice. What is new and different is building a protocol for high intensity escalation strategies that uses a standardized approach and sequential steps to ensure the advancement of case management practice as a field of study.
High Intensity Escalation Defined
If advancing the care plan is the methodology fueling case management practice then escalation is the strategic intervention that ensures the care plan is progressing, sequentially and continuously. High intensity escalation is defined as an interventional process that is targeted at the right solution at the right time. This sounds like a rational process if you have less than five patients who can be tracked easily. Try managing 15-20 patients who require a series of interventions at different times to advance the plan of care. With multiple patients, escalation becomes a start-stop approach. Case managers escalate an issue, wait for an answer and are forced to move on to another case that demands attention.
The escalation process is designed for caseloads that are intense in both complexity and volume. Escalation on the surface looks rather straightforward; as barriers emerge, the escalation process is activated by identifying the barriers, contacting the right person who can assist, and removing or minimizing the barrier.
When escalation is used rigorously, it requires intense awareness of the clinical status of each case, including the explicit goals of care and the plan for today coupled with the identification of the orders/actions that will likely occur today. The skillful case manager integrates this information and begins to conduct a further investigation of what actions occurred, or did not, throughout the day. She is trolling for any number of possible delays that will impede the care plan’s progression. One delay, however seemingly insignificant, can stall the plan and cancel the discharge. Always anticipating that impending delays are looming around the corner, the case manager takes immediate and decisive action to escalate the issue when a delay arises.
Escalation, to be effective, requires a well-defined process based on strategies and the details of a particular plan of care. As a process, it is always in a rotational cycle predicated on the status of the case and the barriers that emerge. A primary requirement is that a case manager must have specific information regarding the case to determine if escalation is needed.
Without sufficient plan-of-care information, which is updated throughout the day, the case manager is swinging in the dark. Skilled case managers rely on key steps which are repeated as often as necessary to advance the plan of care and escalate barriers:
- Goals of care and plan for the day are expressed by team.
- Orders/actions associated with the plan of care are initiated.
- Orders/actions that fail or are canceled are reviewed to ascertain their impact on the plan of care and discharge.
- Real or emerging barriers are identified.
- Assess how the barrier can be eliminated/minimized.
- Escalate through the appropriate chain of command within the organization or with community provider/s to eliminate/minimize the barrier.
- New interventions are formulated and targeted.
Examples of High Intensity Escalation Protocol
In each of the examples it is important to note that the escalation process is rational and sequential. But what is most important is that the length of time between each escalation step is very short to ensure resolution.
What happens in most situations is that the case manager may start on an escalation step but get sidetracked on another case. The escalation process, to be effective, must be focused and steadfast. The question is how to accomplish this with a significant caseload. That question is not easily resolved and needs to be addressed within the department as to appropriate strategies. What is an absolute is that unless escalation is focused and sequential, barriers will not be resolved nor will the discharge plan be consummated.
Final Thoughts
Escalation is not a panacea but it is a critical strategy to ensure the care plan is advancing. For high intensity escalation to be effective, the interdisciplinary plan of care must be fully vetted, accessible and serve as the communication resource for updating patients, the clinical care team, payers and post-acute providers. Without an accurate and accessible plan of care, the team’s actions may be fragmented or even be at cross purposes.
Health care reform changes will bring many new challenges that require case management practice to evolve strategies that are demonstrably effective. Each organization must determine an escalation protocol that is accessible and sustainable.
It is imperative that we are ready to respond to the impending health care changes—whatever they may be.
Marcia Colone, PhD, LCSW, ACM, is the Director of Care Coordination at UCLA Health System in Los Angeles, Calif. (
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