EXECUTIVE SUMMARY
Omicron caused a perfect storm of too few employees, too many patients, and case managers becoming even more creative and flexible in transitions of care.
- Fewer patients needed intensive care unit beds, but more were bottlenecked in emergency departments, waiting for beds on the inpatient unit.
- Due to employees out sick with omicron, transitions to ambulatory care were blocked by staffing shortages in skilled nursing facilities, ambulance services, and other home health organizations.
- Some payers tried to ease the bottleneck by not requiring authorization for the next site of care, but this was limited by capacity at other community organizations.
The bottleneck of patients many health systems experienced in early winter was created by a perfect storm of these problems: too few employees, too many patients sick with the omicron variant, and too many ambulatory settings also experiencing staffing problems.
Hospitals continue redeploying staff. The National Guard was called in to help. But when beds are full because patients are too sick to go home without some assistance from a skilled nursing facility (SNF) or home care — and those organizations are not taking new patients due to capacity problems — the bottleneck continues.
“Case managers are showing how valuable they are,” says Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM, senior director of care management nursing for Cleveland Clinic. “What case managers are really good at is pivoting. If a plan is not working, they’ll try another plan, and that’s always been their skill. Now, I think other disciplines are recognizing that talent.”
Sometimes, physicians or nurses will ask case managers, “Have you tried this?” “The case manager says, ‘Yeah, that was five steps back,’” Davis adds. “Most of them do not know what we do; they just know it gets done.”
But they can only find so much flexibility in an overburdened system of healthcare entities that rely heavily on everything flowing in one direction.
One of the biggest challenges is patients waiting in the emergency department (ED) for beds on the inpatient unit, says Mary Beth Pace, RN, BSN, MBA, CCM, vice president of care management at Trinity Health in Livonia, MI.
“Not as many patients require ICU beds at this phase of the pandemic,” Pace explains.
However, it is difficult to transition patients from hospital beds to ambulatory care or to home with care services. “We’re missing so much staffing — not just frontline nurses, but also dietary aides, housekeeping, and it’s starting to affect case management as well,” Pace notes. “A lot of that is those who are close to retirement are choosing to retire. The other thing is quarantining the team because they were exposed or COVID-19-positive.”
The staffing problems extend to ambulatory settings, home health, and even companies necessary for care transitions to function well.
“If we want to transport a patient back to their home in Tennessee, and our ambulance company’s drivers are sick, this can have a kind of domino effect,” Davis says.
Case Managers Get Creative
Organizations can be more creative in funding services to help reduce the bottleneck. For example, case managers could suggest the health system pay for a different ambulance service. “That’s more cost-effective than keeping a patient in an acute care bed,” Davis says. “If there’s not an ambulance available from the resource you normally use, or if there isn’t anyone willing to pay for it, then it makes sense for the hospital to pay for it rather than keeping a patient in the bed.”
Redeploying case management services to help overburdened groups also can help.
“For a little bit of time, we had our utilization management team report to case management,” Davis says. “When they realized how short-staffed the hospital was, they also stepped in and did case management assessments by phone for our patients, stopping what they were doing with utilization management and insurance reviews.”
Another tactic is to flip the case management priorities around compared to what they were pre-pandemic. During a crisis, when it is imperative to transition patients because of overcrowded EDs, case managers can move the very ill and long-term patients to a lower priority to transition than those who could be sent home with only a little extra support.
“Rather than focus on long-term patients with a lot of problems, focus on the low-hanging fruit, those who have the ability to move,” Davis explains. “Some hospitals would say they have always done that, but for big facilities that hasn’t always been the focus.”
This way, more patients could be discharged home after receiving additional support and education. “We try to send everyone home who we can vs. sending them to another facility,” Davis explains. “But some patients have to go to another facility, and the skilled nursing facilities are saying that if a patient has COVID, it’s 10 days before they can take them.”
SNFs at Crisis Point
The staffing levels at SNFs also are at a crisis point, contributing to the bottleneck in care transition. “SNFs are struggling more than acute care hospitals in being able to handle their residents,” Pace says. “That has been a huge barrier to us across all 24 of our states, and it varies from state to state when challenges hit. We’ve even had some SNFs that wouldn’t take their own residents they sent us, and it was because of unsafe staffing levels.”
Some payers are helping by not requiring authorization for the next site of care. But if no SNFs or ambulatory facilities are available, this does not solve the problem, says Colleen Parks, MSN, CCM, ACM-RN, CMAC, director of system care management for Trinity Health. Case managers can adapt to these care transition roadblocks by coming up with a different, but still safe, plan.
For instance, if a case manager cannot find a SNF for a patient, it might be safe to keep the patient in the hospital for several more days and for the hospital’s therapy team to work with the patient before he or she can be discharged, Davis suggests.
“Everyone can change their way of thinking from being a consultant to being a treating provider or therapist right now so we can get the patient moved,” she explains.
This is similar to how case managers have always created backup plans for transitioning their patients. In non-pandemic times, if a patient would benefit from care in a SNF, but the patient’s payer does not agree, then case managers help the patient find a different plan.
Home care agencies also have experienced staffing issues. If it is not possible to make those referrals, one tactic is to work with patients’ families and caregivers to teach them how to care for the patient.
“We’ve had terrible trouble finding home care agencies because of staffing,” Davis says. “We have had to ask families to do more. They can learn how to do some things while they’re in the hospital.”
While this is not ideal — shifting care to family members can be frightening for patients — it’s the best option when the patient needs to go home and home healthcare is not an option.
“If you can’t find anyone else, you teach them in the hospital and send them home, then check with them by phone to see how they are doing,” Davis explains. “We’re trying to be as flexible as we can and keep the patient safe, doing follow-up phone calls from our ambulatory case management team.”
Case management leaders and care coordinators are learning a great deal about how to manage patient care and transitions during a major and long-lasting crisis. But the key is to remain flexible. What worked at the beginning of the pandemic might not have worked well in the second or third phases.
“People were thinking two years ago, ‘We’ll write a playbook,’ but it’s a different chapter of that playbook now,” Davis says. “We’re thinking about what has worked, what didn’t work.”
They learned it is possible to conduct case management assessments by phone, although it is not ideal.
“Most of us would prefer to meet a patient in person, but we learned that we can definitely [call them], and it works,” Davis adds. “We became innovative with what’s the best way to reach a patient.”
The bottleneck of patients many health systems experienced in early winter was created by a perfect storm of these problems: too few employees, too many patients sick with the omicron variant, and too many ambulatory settings also experiencing staffing problems.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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