Critical Path Network
Assigning CMs to cancer program improves throughput
Anticipate the needs of patients during hospitalization
When Lee H. Moffitt Cancer Center in Tampa, FL, redesigned its case management department and assigned case managers by program, patient throughput increased and length of stay dropped.
During a pilot project in the hematology program, the initiative improved patient throughput and increased bed capacity, decreasing the length of stay by half a day and increasing the number of patients treated over a two-month period of time by 50.
"The initial thrust was not necessarily to decrease length of stay but to ensure that it was medically necessary for the patients to be here by removing barriers to discharge. We did find that the length of stay went down because the case managers became knowledgeable about the disease entity and treatment process. This makes them better to anticipate the needs of the patients as they go through the treatment process and better identify their discharge needs," says Linda Pearson Hodges, RN, MBA, CCM, ACM, CPHQ, manager of the case management department.
As a National Cancer Institute Comprehensive Cancer Center, Moffitt treats more than 7,200 patients a year in its 162-bed inpatient units and records more than 252,000 outpatient visits a year. The hospital's blood and marrow transplant program is the largest in the Southeast.
The hospital is at capacity all the time, with patients waiting at home to be called in for treatment.
Case managers are assigned to either the outpatient clinics or the inpatient setting by program. The staffing ratios depend on the volume and complexity of the patients. For instance, the bone marrow transplant program has two inpatient case managers and one outpatient case manager.
Outpatient case managers review the clinic's daily schedule, looking for patients with issues that need to be addressed, such as nonparticipating insurance companies or insurance problems that need to be resolved.
When patients are referred to Moffitt's outpatient clinics, the program's outpatient case managers review the records to make sure that the patient is physically and clinically ready to be seen by the doctor.
For instance, they assist in making sure the hospital has the patient's appropriate medical record and records of biopsies and that the patient is being seen by an appropriate clinic
Some patients are self-referrals and don't know whether they should be seen in the thoracic clinic or the sarcoma clinic.
"The case manager is a clinician and can determine which program will best meet the patient's needs. Another advantage of being assigned by program is that the case manager knows what her program requires and what will be needed when a patient sits down with a physician," she says.
The hospital has employees who do the initial insurance verification and authorization for patients who come to Moffitt for evaluation but when a patient is going to be treated at that facility, the outpatient case manager meets with them and goes over all the insurance benefits, outlining what the insurance will pay, the anticipated course of treatment and drugs needed, and any copay for which the patient will be responsible.
"Having the outpatient case manager gather this information before admission allows the inpatient case manager to start discharge planning much earlier than the actual admission, speeding patient throughput," she says.
For instance, when patients are undergoing a bone marrow transplant, the case managers go over the process with the patient, covering what will happen during and after the transplant, what the insurance covers, what expenses could be out of pocket, expected costs, and issues after transplant.
The case managers talk to the patients about what they can expect after discharge and calls in dietitians to discuss nutrition and dietary needs. The social worker conducts psychosocial interventions to help the patients deal with the stress and depression that frequently go along with a bone marrow transplant.
Throughout the whole process, the case manager keeps the insurance company apprised of what is going on with the patient.
Case managers who are assigned to specific programs become familiar with the protocol and can anticipate what the patient will need during the stay and after discharge, and communicate it to the insurance company, Hodges says.
"They make sure that the insurance company authorizes the continued stay, home health needs, and whatever drugs are required, and that all insurance authorization is completed by the day of discharge," she says.
For instance, the medications that a bone marrow transplant patient may need to take are not stocked by some pharmacies. The case managers call ahead to find out if a pharmacy near the patient's home can fill the prescriptions or if the hospital needs to fill them at its the retail pharmacy.
The case managers attend tumor board meetings once a week during which the oncologists discuss new patients and make recommendations for treatment. The case managers collaborate with the physicians to come up with a plan that will best utilize the patient's insurance benefits.
For instance, the case manager may tell the physician that a patient's insurance requires that a specific home health company provide the needed services.
Sometimes the physicians can alter the treatment plan to accommodate the patient's insurance benefits. Other times, the case manager must alert the patient that a necessary service won't be covered.
"When a physician says a procedure not covered by insurance is really needed, we give the patient an advance notice of noncoverage. We don't want to get to the end of the treatment and hand patients a bill they're not expecting. There should be no surprises at the end of treatment," she says.
Often the case managers can suggest that patients who are otherwise ready for discharge receive physical therapy or another treatment at a lower level of care.
"Our case managers walk that fence between the business and the clinical side and they walk it very well," she says.
Case managers and social workers round with the treatment team.
"We don't wait for an order for a social work consult. If there is a psychosocial issue, we talk to the social worker right then," she says.
If there are social issues that may impede discharge, the case manager brings in the social worker to make arrangements for community support before the day of discharge.
"Any acute care discharge plan may fall apart. It's harder for us because many of our patients don't live around the block. We have to think about discharge much earlier," she says.
For instance, after a bone marrow transplant, patients receive daily IV infusions in the clinic every day for a certain amount of time, and then come in for treatment once a week.
"Eventually, they go back to their local physician for interim follow-up and come here monthly, then quarterly, but if we've done the transplant, they always come to Moffitt for follow-up," she says.
The case managers and social workers collaborate early in the stay to make discharge arrangements so the patient can come back for the follow-up visits.
"If a patient lives a good distance away, we work with the social worker to find lodging close by. The whole idea is not to wait until discharge. We start a conversation about discharge in the clinic setting or during tumor board meetings when the treatment plan is being developed," she says.
Patients who live out of town may be able to stay at the American Cancer Society's Hope Lodge or apartments leased by Moffitt for transplant patients.
In some cases, the case manager may set it up for the patient to have home infusion but come into the clinic for blood work and other laboratory tests.
When patients from out of town receive surgery at Moffitt and need radiation treatment or chemo-therapy, the case managers try to arrange for them to receive the treatments in their hometowns.
"We try to locate physicians who will take over their care and communicate to us what is going on. If a patient comes in for a second opinion and can receive the recommended treatment close to home, we try to facilitate that," she says.
If the patient needs treatment protocols that must be given at Moffitt, the case managers and social workers arrange for the patient to stay in Tampa during the treatment.
Drugs that are given as part of cancer treatment are expensive and some are not covered by some insurance carriers.
When case managers determine that a patient's insurance won't cover a particular drug or the patient has no payer source, they turn the information over to the hospital's department that is dedicated to applying for drug assistance. So far this year, the hospital has received more than $5 million in reimbursement from drug companies.
When Lee H. Moffitt Cancer Center in Tampa, FL, redesigned its case management department and assigned case managers by program, patient throughput increased and length of stay dropped.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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