Discharge Planning Advisor
Administrators fall short of full recognition of CM duties
Staffing models often out of date
Until a hospital's executive administrators truly acknowledge that case management is part of the cost of doing business, it's likely that those charged with performing that task will continue to struggle with daunting workloads and inadequate staffing, says Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of the Center for Case Management in South Natick, MA.
"It's like people who want to run a department store but don't want to buy clothing or racks or cash registers," she adds. "Then the ones who need those things are in the position of saying, 'What is our return on investment?'"
Although there is some movement toward recognizing case management as part of a health care organization's basic structure, Zander says, it often fails to include a full acceptance and understanding of all the necessary case management functions — utilization review (UR), discharge planning, access, and care coordination.
With increasingly complex cases and more and more uninsured patients, traditional case management staffing models have become obsolete, suggests Kate Tenney, RN, manager for case management at Sutter General Hospital in Sacramento, CA.
"In the old days, with the original case management staffing models," she adds, "you took the overall census and determined which patients would need utilization review, which would need discharge planning and some coding documentation, and then calculate staffing based on, for example, UR takes 20 minutes and discharge planning maybe 45 minutes."
With current patient acuity levels, however, those time studies are no longer accurate, Tenney says. "I have case managers who have large caseloads of homeless, uninsured, young patients with multiple diagnoses.
"It used to be that if a patient was 45 years old, he didn't require anything but UR," she says. "Now that 45-year-old has hypertension, diabetes, is a smoker, and has peripheral vascular disease."
In addition, that patient might be a drug user with wounds that are infected because he lives on the street, Tenney adds. "Since he has no insurance and is homeless, there is no place in the community he can go. Skilled nursing facilities are not geared to the young."
The picture doesn't even have to be that bad for the case to be a challenge, notes Barbara Leach, RN, director of case management for Sacramento Yolo Sutter Health.
"Say the person is a skilled worker, works for a mom-and-pop operation [and so doesn't have insurance] and barely pays the rent," she says. "We have a 57-year-old who has lived [in the hospital] more often than not because [he needs post-acute care] and there isn't anywhere else for him to go."
Adding to the pressure is the faster turnarounds that have been expected since the advent of the hospitalist program, Leach points out. "If there is a test in the morning, [hospitalists] are expecting to do something by that afternoon."
In the past, case managers would open a case in the morning, spend 30 minutes on it, and not touch that case again for 24 hours, adds Tenney. Now, the hospitalist handling the case might come back to it during the day — multiple times — necessitating more involvement by the case manager.
Not only is medical care more complicated, there are more accompanying questions that need to be asked, Zander says, citing a hospital case on which she recently consulted.
"The patient had a burst aneurysm and was pretty much out of it, and had a bad skin breakdown from being in a nursing home," she explains. "The hospital staff was upset because there was no DNR order. The patient, who now was having an infectious process, had already been in the hospital eight days, but nobody had talked to her husband about any of this."
The man didn't come in at a time when it was convenient for a member of the staff to talk with him, and the patient was still sick enough to need utilization review, Zander says. "Nobody was talking about 'the middle part' of care. We can save her life, but does her husband actually even know how her body looks under the sheets, how deep the wounds are? You don't come back from that."
In this instance, the hospital involved didn't have case management, she notes, so there was no one saying to the husband, "If [the patient] goes into a code, what do you want to do?
"The case manager is the catalyst for asking the right questions," Zander says.
New staffing models in order?
Despite these increasing demands on the case manager's time and expertise and the demonstrated need for someone whose job is to ask those kinds of questions, Tenney says most hospital budgets are dependent on that initial staffing model.
A reevaluation of staffing ratios is obviously in order, Leach says, but the fact that models vary a great deal among hospitals complicates the issue.
"Some hospitals do not have what we call an integrated model," she adds. "At Sutter, our case managers do UR, discharge planning, and a fair amount of care coordination. In other hospitals, those are all distinct roles, which makes it hard to compare models and staffing."
At some hospitals, notes Tenney, social workers do a great deal of discharge planning, and at others they don't do any part of it.
Leach says she has done some "work sampling," whereby one identifies categories of work that are expected to occur and then observes staff to see what category they are performing at particular intervals.
"You can say you spend 30% of your time doing this, and 60% doing this," she explains, but work sampling can reveal that those percentages are way off. In an "80-20 world," where the most intense work takes up 20% of one's time, Leach adds, "20% feels like more. You always write down the things that drive you insane."
To help relieve the staffing crunch, she says, Sutter Health has added "nurse extenders" to help relieve the staffing crunch, she says.
The drawback there, however, is that most of the increased demands on case managers require nursing expertise, Leach notes. "The nurse extender can't assess the results of a critical test or resolve a complicated family dynamic or determine what level of care the patient needs."
At Sutter Health, explains Tenney, these nurse extenders are known as case management specialists. They act as assistants to the case managers and do provide invaluable help, she says.
"The job description requires some college education and some background in medical care," Tenney says. "[Case management specialists] are responsible for the entire placement process once the case manager has identified what is needed."
A certain percentage of time in the staffing model is calculated for placement, she notes. "The nurse extender can pull that [function] out of the nursing model, and the case manager can handle twice as many patients that will need placements because of the nurse extender positions."
At Sutter General, four specialists do 800 placements a year, Tenney says. "The other piece [they perform] is that once the case manager has determined that a patient will go to an SNF, the specialist will meet with the family, coordinate the actual transfer including transportation, communicate with the SNF, and copy charts.
"So basically, the specialist will make all the arrangements and follow through and then back it up with documentation," she adds. "So a case manager can hand off the rest of the case to that person. It's one thing to have a clerical person who can make copies, but to have a person you can hand a case to is a huge help for case managers."
While the nurse extender helps with a piece of the case manager's work, what Leach refers to as "how long it took to Xerox something" has been eliminated from the case manager's schedule. "It took away that down time, that time to think.
"Because we've moved hospitals into a 24-7 operation," Tenney adds, "case managers are constantly trying to maneuver patients and keep up with documentation."
Under normal circumstances, managers would go to the hospital's administrative team and say more case managers are needed because of the acuity of the patients, she says, "but in the current environment, that's not an option anymore."
Instead, the focus at Sutter General is to bring down the number of full-time equivalents per discharge, Tenney continues, because it's higher than at other facilities in the community.
To make the most of the staffing that is available, she says, "we concentrate on making the case managers as efficient as possible. We try to train them not to take on other people's jobs."
The tendency, Tenney explains, is for case managers to do a lot of things that are not part of the case management role, such as helping nurses and physical therapists with their tasks, because it facilitates discharge.
"For instance, the physician writes that the patient can go home as soon as his labs are normal," she says. "The case manager will go to the nurse and say, 'The labs are normal. Is the physician going to discharge?'"
The nurse, Tenney adds, will respond, "I don't know. I didn't know the labs were normal." Under normal circumstances, she says, the case manager will then call the physician and go back to the nurse and say, "Here are your orders for discharge."
Other staff members may not be as aware of time and length of stay, as well as other patient issues, as case managers, Tenney notes, which can lead to another potential drain on case management resources.
"Traditionally, on any hospital unit, the case manager was the center of information if someone didn't know what was going on," she says. Being that resource for a unit is very time consuming, Tenney adds, and not realistic in today's environment.
"Ask yourself," she advises case managers, "Can you afford to take every phone call of every nurse and physician that comes by to talk to you? Time is such an issue. That [pattern] may have to change."
Another lesson case managers may need to learn, Leach points out, is when to give up — at least for the time being.
In many instances, she says, case managers will concentrate on a very difficult case, in which the living conditions, the age and attitude of the patient, and perhaps the lack of family involvement make it extremely unlikely that the patient can be readied for discharge.
"When staff tell me about a situation like this," Leach says, "I tell them, 'Put this down. Work on it again tomorrow. It wouldn't get done today anyway, and you need to move on to the five other patients you haven't seen at all. Make sure you don't [negatively] impact cases you can make a difference on.'"
(Editor's note: Karen Zander may be reached at [email protected]. Kate Tenney may be reached at [email protected]. Barbara Leach may be reached at [email protected].)
Until a hospital's executive administrators truly acknowledge that case management is part of the cost of doing business, it's likely that those charged with performing that task will continue to struggle with daunting workloads and inadequate staffing, says Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of the Center for Case Management in South Natick, MA.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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