The increasing complexity of healthcare has taken the field of case management along for the ride, and with it the practice of utilization management.
“The four roles of case management have become more complex — utilization management, discharge planning, care coordination, and resource management,” says Beverly Cunningham, RN, MS, ACM, partner and consultant at Case Management Concepts, LLC. “Each requires increased balanced, significant interventions by the case manager, taking more and more of the limited time a case manager has in his or her day to focus on these four roles.”
Utilization management (UM) has become much more comprehensive, notably with payers. “Payers have ‘loose’ rules and regulations, meaning they seem to change the rules as it fits each circumstance/patient,” Cunningham explains. “Each payer has their own rules and regulations, and seem to do whatever it takes to not pay for services rendered to their members. Medicare has also become more prescriptive in their expectations for utilization management.”
With these regulatory challenges, case managers must “spend more time collaborating with physicians to ensure documentation in the medical record accurately describes the severity of illness and next steps in the medical plan for the patient,” Cunningham says. “It is much more difficult for physicians to understand the expectations of the various payers.”
One helpful asset is the physician advisor, which Cunningham recommends for each hospital, as the role requires significant knowledge, excellent communication skills, and perseverance, “especially when working with payer medical directors.” Larger hospitals might need multiple physician advisors.
Another challenge includes the emerging practice in some hospitals of removing UM from the bedside, making it a remote position. This often happens because payers have many varied requirements, yet it results in a greater challenge to the case manager on the unit to understand the expectations for each payer.
“This is especially challenging with a large case load,” Cunningham says. “As UM has separated from the traditional role of the unit case manager, there is an increased need for collaboration between the staff doing UM and the case manager on the hospital unit. Additionally, the physician now has to communicate with [both] a case manager on the unit and the UM staff. A sense of urgency is critical [for both UM and discharge planning] as patients are transitioned through a hospital. When there are several case managers — on the unit and the UM staff — that urgency is often lost.”
Best Practices
Regardless of these challenges and changes, case managers have a great opportunity to employ several best practices to bring consistency to the UM process, and successfully contribute to the overall management of each patient’s stay.
• Bring clarity to the UM role. While there is no cookie cutter answer to the best model of UM, says Cunningham, it is important to thoroughly vet the appropriate role in each hospital. This is especially helpful when onboarding new staff. Likewise, setting clear goals for the organization and team can help promote a healthy environment.
• Hire appropriate clinical staff. “If the UM team has a strong clinical background, then a clearer understanding of the disease process will help plan for effective use of resources,” says Pat Wilson, MBA, BSN, RN, director of care transition management at Texas Health Presbyterian Hospital. “A cohesive team will support and help one another so collaboration becomes the norm.”
• Orientation is critical for success. Cunningham and Wilson agree staff must undergo adequate orientation and an annual competence review. “If the UM employee is hired from outside your organization, assigning a mentor who can translate the culture will lead to positive relationships with the physicians and care team,” Wilson says. Connecting with the recommendation above to bring clarity to the role, it also is important to define the expectations of the role, ensure it mirrors the job description, and ensure the team has the resources necessary for positive outcomes and cost-effective patient management.
• Recognize the multidisciplinary nature of UM. While UM is a case management role, the entire multidisciplinary team contributes to it. “While a case manager and social worker may be [handling] timely coordination of care in preparing the patient for discharge, delays can occur by other hospital staff,” Cunningham explains. “If nursing does not ambulate a patient, or even get them in a chair for meals, their progress will be slowed, and can delay their discharge. Medication errors may extend the hospital stay. For example, delayed tests from radiology can delay either discharge of a patient or delay the physician’s determination of next step in treatment of a patient. Additionally, lack of availability of weekend testing and surgery can delay a patient’s discharge.”
• Prioritize continuing education. Cunningham and Wilson recommend periodic and ongoing education of staff, especially when rules and regulations change. Regular feedback for staff also enhances education opportunities.
• Establish an effective physician advisor program. “It’s important to maintain an active participation with patient access, physician advisors, and utilization review if this is not within the scope of the case manager,” Wilson suggests.
• Say yes to rounds. Cunningham suggests case managers should participate in “case management leadership rounding with staff to increase awareness of their challenges and any compliance errors that may be occurring.” Daily multidisciplinary rounds are “an absolute must,” she adds. Bedside rounds are optimal. UM staff also should participate. Wilson agrees, stating this offers an “opportunity to address any barriers for discharge with the team” as well as presenting “a united front with the patient and family.”
• Communication. Wilson emphasizes the importance of written and spoken communication, and encourages case managers to “listen, listen, listen.” Case managers should hone the skills and ability necessary to “meet people where they are, [including] the physicians, care team, patients, families, and post-acute providers,” she adds.
• Attention to detail. “Ensure your managed care contracts contain appropriate UM verbiage,” Cunningham says. “If you don’t have it in the contract, the payer has no guidance for your expectations.”
Case managers should strive to be aware of “payer mix and demographics, and build a strong body of community resources that is refreshed at least quarterly,” Wilson adds.
• Organization, boundaries, and responsibility. Since case managers face multiple competing priorities throughout the day, staying organized will alleviate the stress, keep the case manager on track, and prevent crises, Wilson says. Setting boundaries are important, and there are limitations in every situation. “Do the best you can today, and take responsibility for your actions, both the good and the bad,” she notes.
While the list of best practices may seem unattainable at first, Cunningham suggests case managers identify a mentor in the department if one has not been assigned. Other allies include supervisors, and even physicians, both of whom the case manager should strive to collaborate with daily.
In the meantime, understanding the big picture of UM and what it entails, and continuing to learn how to incorporate it into the daily routine, will help case managers become more proficient. The result will be fewer denials, less confusion for the team, and a decrease in delays in care — all of which lead to a better patient, staff, and hospital experience.
The increasing complexity of healthcare has taken the field of case management along for the ride, and with it the practice of utilization management.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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