Case managers emerge as crux of hospitalist team
Improvements seen in LOS, utilization of services
As hospitalist teams continue to emerge, one potential team member is often omitted: the case manager. One hospital and its partners solved that problem, however, by establishing case managers as integral team members and ultimately making them the leaders of daily rounds.
According to Tracy Figueredo, RN, BSN, case manager at Rex Hospital in Raleigh, NC, the members of the newly formed hospitalist team were drawn from three separate entities — Kaiser Permanente, Carolina Permanente, and Rex Hospital — that joined forces to establish the team. "We wanted to provide hospitalist services, and we needed to bring together all three of these entities to accomplish that," she explains.
Rex Hospital is a 400-bed acute care hospital. Carolina Permanente Medical Group was a group practice in Raleigh that worked exclusively for Kaiser Permanente and was responsible for 65,000 commercial lives. The group was made up of 60 practitioners including physicians, nurse practitioners, health care extenders, and physician assistants. It also included internists, pediatric physicians, OB-GYNs, dermatologists, and other specialists.
Under the hospitalist team design, case managers worked for the payer and the hospital but were based at the hospital, where they worked exclusively with a group of physicians on the hospitalist team. Importantly, hospitalists were rotated to provide continuous coverage. "There was a physician there 24 hours a day, which was somewhat unique," Figueredo says.
The model also included social workers. Figueredo maintains that while some people now advocate eliminating social workers, that is not always a sound practice because case managers typically are RNs who lack practical social work experience. Rather than dedicate social workers to the team, however, they were made available on an as-needed basis.
According to Figueredo, the hospitalist team saw a variety of patients but focused on adult medicine service lines. It also acted as a consultant for specialty services. In some cases, the team also saw emergency department cases and unassigned primary care patients.
Figueredo points out that many physicians in the community already were eager for more information about what was happening to their patients while they were in the hospital as well as after they were discharged. "The physicians needed to interact with the primary care physician, and they also needed to interact with the specialist," she explains.
The hospitalist team provided that mechanism. It also helped establish itself as a team concept, says Figueredo. "We are all a team, and to be a team, we need to sit together in the same room and talk about the patient," she explains.
Medical director didn’t micromanage
The other team member was the medical director, who was given responsibility for oversight of hospitalist physicians and their clinical practice. Notably, the medical director was tasked with overseeing movement of the patient along the continuum and physician education rather than micromanaging clinical treatment, she adds.
According to Figueredo, case managers had an extensive list of responsibilities, including the overall care of the patient, utilization review and utilization management activities, discharge planning, and quality screening.
Utilization review and utilization management in this scenario meant concurrent review, says Figueredo. That included a determination of why patients were admitted and the severity of illness, as well as the level of care they were receiving. Case managers also performed emergency department triage for admissions to help coordinate services in cases where a physician might otherwise admit patients if no alternative was immediately provided.
The case manager also was tasked with coordinating and orchestrating the discharge plan, which started on the first day and used a multidisciplinary approach. If patients were newly diagnosed with diabetes, that meant linking them with community resources such as a diabetes educator. If they had a new ostomy, it meant consulting an ostomy nurse early in the process. If those patients were going to receive home health services or skilled nursing, it meant contacting the necessary vendors.
The case manager also monitored readmissions and tracked whether they had occurred because of a clinical problem, a systems problem, or a compliance problem. They also performed follow-up appointment calls, an item that is frequently overlooked as patient load increases, Figueredo says.
Team did rounds together
According to Figueredo, team rounds were critical to the hospitalist team approach. All the components of the team participated in the morning rounds, including the hospitalist team physicians and the medical director. If social workers were required, they participated as well.
"We even had an exclusive relationship with a skilled nursing facility that wanted to partner with us that was invited," adds Figueredo. That often led to discharging patients to skilled nursing earlier in the process because physicians immediately became aware of the services the skilled nursing facility could provide. While the hospital initially was concerned about confidentiality issues, those concerns were successfully addressed, she explains.
Every case was discussed during rounds, with an immediate emphasis placed on the discharge plan. Short afternoon rounds for problem cases also were performed, in part to address any concerns that might be raised in the interim by a family member or other party.
Initially, the physician was the leader of the team, Figueredo says. Not surprisingly, however, physicians were almost exclusively interested in medical issues. "The physicians were too clinically focused," she reports. "We quickly decided that strategy was not going to work." The medical director was viewed as a poor alternative because he was not dedicated to the team, she adds.
Instead, case managers became responsible for the overall plan. "We thought the case manager was the best person to lead the team," she reports. "Once we did that, it was interesting how quickly the hospitalist physicians bought into that concept."
One of the most important outcomes of the team approach was total patient care coordination, Figueredo says. "We now had a system where the social worker, the case manager, and the physicians were all working on the same team to get the job done." Physicians no longer were blamed for denials, and when readmissions did occur, both physicians and case managers became more actively involved in establishing preventive plans, she explains.
Lower costs, decreased length of stay
This provided a continuity of care not often found when a patient is admitted by a primary care practice that has eight or 10 partners in the practice, she says. "They often can’t remember what the last person did, and nobody remembers what the case managers did," she asserts.
Another result was improved utilization of services, Figueredo says. "We saw decreased costs because we established a norm for how you treat certain patients." In fact, the team often adopted standard clinical practices regarding certain treatments, she adds.
Because the team was employed by the hospital, it zeroed in on costs. "[The team] knew it was not going to get more physicians to work for it if the costs were too high or if they were overutilizers," she says. There was also a decreased length of stay with less variability, she adds.
As a 400-bed hospital with only two surgical groups, Figueredo says, it was possible to help the surgical practice move their patients through a continuum. One example was bowel surgery patients. Traditionally, those surgeons opted to not feed the patients for up to three days after surgery. However, in order to get bowel function back, that timetable was expedited, and the seven- or eight-day lengths of stay associated with bowel surgeries were eliminated.
Quality of care improved as well, Figueredo says. In fact, the hospitalist team still exists and plans to publish data this year showing that the team has a lower mortality rate than anybody else in the hospital. The primary reason for this is that the physician is there 24 hours a day, seven days a week, she adds.
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