Access, CM functions overlap for patient needs
'How do you get a control point?'
The clinical expertise of case management is increasingly being used in the access process, and in the next five years many of the functions of the two disciplines will be consolidated, says Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner at the Center for Case Management in South Natick, MA.
"Case management staff are being asked to run the bed board, to have somebody in admitting and registration, to have a utilization review person doing preauthorization and precertification," Zander adds.
That overlap can only increase as hospitals and health care systems grapple with the many ways in which patients access care, she suggests, citing a client that is a well-known tertiary medical center in a rural area.
"There are patients admitted from the emergency department, direct admits from physician offices, acute-to-acute transfers, and people coming in on helicopters," Zander says. "How do you control all these doorways to your center? Who decides who comes and when and what bed to put them in? The ED is pushing for beds and post-surgical [staff] are pushing for beds.
"The challenge," she notes, "is, 'How do you get a control point?' Do you keep having a variety of ways to get in or do you consolidate it?"
Adding to that challenge is the fact that the process goes on 24 hours a day, and that it involves an intricate mix of medical, financial, and regulatory concerns, Zander says. "The more people see that these are clinical discussions plus regulation plus reimbursement, the more case management will start to influence the access piece."
"In the old days," she points out, "if you needed a bed in off-hours, the nursing supervisor would canvas the hospital, decide what bed was available, and the patient would go there. Now it's much more complicated. There's a higher demand for beds and for immediate decisions."
While she believes that access will take on much more of a clinical judgment role, Zander says there is no clear answer as to whether the top decision maker in the process will come from the access or the case management arena.
"In my experience, the person that gets given this bigger scope is the person who has been successful in smaller scopes," she says. "The boss will be the person who has proved herself in other ways."
Zander says she could see a physician being part of access, especially at a tertiary medical center with direct admits.
In addition, she says she would like, in the case of a health system, for clinical and support people to have the authority to place patients in beds throughout the system, not just at the facility where the patients present.
"There is a very cumbersome process now, where an acute rehabilitation facility has to send a representative to the hospital, assess patients, and then go back and see if they really have a bed," Zander notes. "I see all the middle stuff being cut out and, through clinical judgment and criteria, [intake staff] saying, 'It's time for acute rehab'" and finding a place for the patient within that system.
That would be with the patient's permission, she emphasizes. "It all has to do with patient choice, but if patients choose that, and that's what they need, let's just get them there — or to a skilled nursing facility or home care [if that's what is needed]."
This could be a patient in the ED, or one currently in a bed, Zander notes, "but instead of having case management call agencies and say, 'Do you have a bed?' have one access person say, 'We have this bed [within the health system].' It takes a lot more personnel to have the process we have now."
Taking her access concept further, Zander says she advocates consolidating all of the entrance points — and the decisions on who can come into a hospital — in one department.
In addition to having bed booking available beyond the walls of the hospital, she says, functions such as transport would be centrally coordinated. In many health facilities at present, Zander notes, "if you need transport for a patient, the secretary on the maternity unit also covers that, and the admitting office covers something else, and there is an internal transport staff that take patients around inside the facility.
"If you think about the definition of access and how far you can spread that and how serious you can get about it, whole new models come to mind," she says. "It's like being the nerve center, like air traffic control. It's bed traffic control."
[Editor's note: Karen Zander can be reached at (508) 651-2600 or by e-mail at [email protected].]
The clinical expertise of case management is increasingly being used in the access process, and in the next five years many of the functions of the two disciplines will be consolidated.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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