By Toni Cesta, PhD, RN, FAAN
Introduction
Case management always has been a paper-intensive discipline. Communicating across the continuum of care between payers, providers, social workers, and case managers means lots of paperwork. We have to complete myriad forms for transportation, home care, patient choice, compliance, referrals to community services, and so on.
Somehow, we have come to accept this paperwork as “just a part of what we do.” We continue to grapple with high caseloads, piles of paperwork, and, often, work that forces us to perform at the bottom of our license. Busying ourselves with tasks that can be safely performed by non-licensed workers means we can’t complete our other projects. We spend much less time with our patients and families, filling out pieces of paper, making phone calls, and chasing after others — resulting in our inability to get the “real” work done. Many times, while we say we are overworked, much of the work we are doing could be performed by others. And yet, so many of our departments do not have this level of support.
In this issue, we will discuss the role of clerical support staff assigned to case managers. There are other ways to reduce the amount of paperwork, such as case management information systems that electronically transfer information. Information systems provide the ability to create a specific choice list for our patients and to send requests for continuing care services. These needs are obvious, and more departments are purchasing such software. However, this is not all that we need — clerical support staff also are important.
You may have heard of such staff, or you may have your own. There are many titles for these staff, including extenders, assistants, associates, expediters, and so on. Titles don’t mean much, but job descriptions do. These positions are filled with individuals who can perform tasks identified by the case management team to support discharge planning, utilization management, and care coordination. These positions do not perform any work that requires professional intervention, but they do require a professional to delegate the work. We will discuss delegation later in this issue.
Transitional Planning
Transitional planning involves the smooth movement of the patient from one level of care to another, and often includes paperwork that can easily be performed by a trained clerical support person. The case management expediter completes tasks related to the transfer of patients to post-acute care facilities or home with services, including the following:
- communicates with facilities related to bed availability, including the use of case management electronic discharge system;
- makes packets for transfer to skilled nursing facilities, nursing homes, rehab, or long-term care hospitals;
- faxes internal referral information;
- ensures transfer documentation is complete;
- arranges transportation, confirms arrangements, and communicates with families regarding transfer arrangements;
- arranges for durable medical equipment in the patient’s home;
- makes follow-up physician appointments;
- maintains and manages knowledge of post-acute settings such as skilled nursing facilities, home care agencies, infusion services, durable medical equipment services, hospice, acute rehab, and long-term acute care facilities on a patient-by-patient basis;
- independent and proactive initiation of duties related to transfer of patients described above.
Compliance
Case managers and social workers have responsibility for some elements of compliance, as they are applied through the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation for Discharge Planning and Utilization Review, the Balanced Budget Act, and the Affordable Care Act, among others. Much of the work associated with managing these elements of compliance involves paperwork and forms. While many of these forms must be delivered directly to patients and families, they don’t always have to be delivered by a licensed professional. The following are a few tasks that can be delegated to the case management extender after proper training:
- provides patient and/or family with Important Message from Medicare letters, as directed by staff;
- delivers Medicare Outpatient Observation Notice (MOON);
- obtains choice selections from patient and family.
Care Coordination
Coordination and facilitation of care is a key role of the hospital case manager. All care coordination-associated tasks are aimed at reducing or eliminating bottlenecks or delays in care. Ultimately, these tasks improve patient flow and length of stay. For the case management extender, this work revolves around the timely completion of extender work so there are no delays. The extender also might be taught how to call radiology or other departments to determine why there is a delay in obtaining a test, treatment, or procedure.
Utilization Management
For the case management extender, utilization management is focused on obtaining authorizations from commercial insurance companies for services or items that the patient may need after discharge. If the hospital does not submit insurance reviews electronically, the extender may be responsible for faxing or scanning reviews to third-party payers. The extender may obtain authorizations from commercial insurance companies for transportation, durable medical equipment, home care or skilled nursing facility care, and medications.
Communication
Proper, timely, and comprehensive communication are important skills for any healthcare provider, including the case management extender. It is critical that those with the best communication skills possible are selected for this role. The extender may be communicating with patients, families, physicians, nurses, third-party payers, and others along the healthcare continuum. Classes on communication techniques are recommended for new hires. Tips for good communication would include the following:
- Ask the RN or social worker when an assigned task must be completed. This could be immediate, within an hour, by the end of the day, etc., so the extender can prioritize the tasks.
- Keep the RN case manager or social worker up to date on the status of the request, should there be a delay.
- Let the case manager or social worker know when the task is completed.
- Keep patients and families updated on the status of any referrals.
- Inform the case manager or social worker of any conversations that they may need to be aware of or follow up on.
- Escalate issues to case manager, social worker, or leadership staff in a timely manner.
Documentation
Whether to have the extender document in the medical record is a choice that each hospital has to make independently. The decision to allow the extender to document should be based on the organization’s policies and procedures. In some instances, the extender may be tasked only with documenting in the department’s case management software. If the extender will not be documenting in the medical record or in the case management software, then the department must determine another way to document completion of tasks. This can be a cumbersome process. Examples of the actions that might need to be documented in the medical record include:
- delivery of the Important Message from Medicare letters to patients;
- delivery of the choice form to the patient and family;
- patient and family’s selection of a skilled nursing facility or home care agency;
- authorization obtained from the third party payer for an item or service.
Caseloads for Extenders
The extender’s role can be as narrow or broad as you choose. If the extender is assigned all the tasks listed above, then there are specific caseloads that I can recommend. The average assignments should be approximately one case management extender to every eight professional staff. This should be a combination of case managers and social workers so that the work is equitably distributed. Whenever possible, try to align the extenders’ assignments to case manager and social worker teams so that “travel” around the hospital is minimized.
Another advantage of having the extender aligned with various case management teams is the opportunity for enhanced communication among and between team members. The team may even want to consider holding a daily huddle to discuss tasks and review any new issues that might have come up during of the day. Midafternoon is probably the best time for such huddles.
You may need to test out the caseloads, as variations among units may require larger or smaller assignments in some areas. For example, if a particular geriatrics unit completes a large number of skilled nursing facility referrals, then the workload on that unit might necessitate a smaller load for the extender.
In my experience, the extender is a very popular role in most hospitals. The role provides for experienced staff to try something new and challenging. For this reason, nursing assistants and unit receptionists often apply for these positions. They make excellent candidates, as they have experience interacting directly with patients, families, physicians, and nurses. They understand how a nursing unit operates and get up to speed fairly quickly. If you have case managers and social workers on the weekends, you should consider having extenders on the weekends as well. Since most case management departments run with smaller staffs on the weekends, the extender can play a vital role in supporting and assisting the professional staff on these days. Be sure to include the ED when you calculate how many extenders you will need.
Orientation to the Role
In order for the extenders to function optimally, they will need two forms of orientation. The first is a class, during which they can learn about case management, the roles of the case manager and social worker, discharge planning, utilization management, and patient flow. They should also be taught about communication and teamwork. These classes should be geared toward those selected for the role in terms of educational preparation and healthcare experience.
The second part of the orientation should provide a mentorship for the extender. The newly hired extender should shadow and work with a more experienced extender until he or she is able to show competency. If you do not have an experienced extender to mentor a new hire, or you are just starting to hire extenders, then the case management leadership team and/or case management staff will have to fill this mentorship role.
Delegation
No matter how many extenders you hire or how well you orient them, if the professional staff do not delegate to them, the positions will not be productive or useful. Case managers and social workers often have difficulty in delegating to professional staff. The reason for this is simply that we are not used to it. We are much more comfortable developing work-around solutions, becoming absorbed in low-level tasks and “busy work” that could comfortably be performed by a nonprofessional.
Delegation is a complex process that requires sophisticated professional judgment and final accountability for the delegated task. While the extender will be assigned a set list of tasks, the variability of each patient situation will require that each task be considered carefully before it is delegated. For example, while it may be appropriate for the extender to give a choice list to a patient, or to pick up the list after the patient has made a selection, there may be situations in which this would not be appropriate. The patient and/or family may be struggling with the decision, or may be hostile about it. In these situations, it may be more appropriate for the social worker to work directly with the patient and family during choice selection.
Matching the staff to the patient and family needs highlights the difference between delegation and assignment. Delegation means that the case manager or social worker is giving a task to the extender that is from their own practice. The extender must be qualified to perform the delegated tasks. An assignment implies a more independent role in which the employee follows a set of tasks independently, based on their job description. This is why an extender cannot simply be given a laundry list of tasks and told to “get to it.”
Case managers and social workers are stewards of healthcare resources. They promote cost containment for healthcare organizations. Delegation is a skill that maximizes the available resources in the interest of patient care. Therefore, case managers and social workers must work effectively with extenders in order to optimize the resources they have been provided. For these reasons, it is imperative the case managers and social workers become skilled delegators who understand the concepts of responsibility, accountability, and authority, and grasp how these concepts influence what activities they can delegate to others.
Responsibility is a two-way process that is given and accepted. An extender accepts responsibility when he or she agrees to perform a delegated task. Accountability requires that case managers and social workers answer for both themselves and others regarding their actions. As a case manager, you ensure accountability by verifying that the extender accepts the delegation and its accompanying responsibility. Case managers and social workers have the authority to transfer tasks to a competent individual based on their professional licensure.
Because so many case managers and social workers have never worked with case management support staff, the notion of delegating may be uncomfortable and/or foreign to them. In order for case management staff to feel comfortable delegating, a number of components must be in place. The first is that the professional staff must have confidence in the ability of the extenders to perform the work delegated to them. The process cannot begin until after the extender has been formally oriented and able to demonstrate competence. This only can be accomplished through time and team-building.
In addition, the professional staff must be aware of how they delegate and how they interact with the extenders as well. Trust is the No. 1 reason why staff often don’t feel comfortable delegating to others. Trust is built as each team member shows respect and a professional manner in their dealings with each other. Healthy professional relationships among team members will result in greater synergy, enabling them to work together effectively and efficiently.
Summary
Healthy, effective, and appropriate delegation is the key to the success of a case management extender program. If you are embarking on this journey toward adding extenders in your department, be sure to orient the extenders thoroughly. In addition, be sure to educate the professional staff on the skills needed for effective and productive delegation. Spend some time team-building as well. Taking the time to do these things up front will increase the likelihood of success with your extender program.
Hiring extenders can add much-needed clerical support to overworked case managers.
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