Redesign of department is a work in progress
Before Thomas Hospital in Fairhope, AL, redesigned its case management program, nurses from two separate departments — social services and utilization review — performed case management-type functions. At that time, the social workers and RNs in the social services department handled discharge planning and provided support for patients and families. The registered nurses and licensed practical nurses (LPNs) in the case management/utilization review department performed utilization review and were beginning to conduct case management on a trial basis.
In 2002, the hospital hired a division director to redesign its case management program and oversee the social work, discharge planning, and utilization review functions. "The first step was to reduce the amount of duplicated work," says Carolyn Williamson, RN, division director. The registered nurses became "care coordinators" with duties that included all the functions previously handled by as many as three staff members. These include patient rounds, assessments, utilization review, and discharge planning. In the initial months, the social workers handled their own patients with support from the LPNs who provided utilization review. The departments were brought together as a team in May 2002.
"We had an opportunity for improvement. The case management department was fairly new at Thomas Hospital. By bringing these departments together, we could enhance communication and coordination of their separate functions," she says.
The initial plan called for cross-training all staff members to handle case management duties, including assessment, rounds, discharge planning, and utilization review. The model has evolved to a team approach with teams of two RN case managers and one social worker assigned to a group of physicians. Currently, all of the positions are filled by RNs and social workers, Williamson says. "Nurses and social workers have strengths that are unique to their individual background and experiences. The case management team approach utilizes these strengths to their greatest advantage," she says.
The teams coordinate care for as many as 30 physicians at a time. The RNs divide the physician list and manage the cases, consulting with the social workers to help with difficult discharge planning issues, placements, and financial assistance. "The teams work together and share duties depending on how much time they have. They pitch in and help each other when one person has a difficult case. If one team is overloaded, we expect the other teams to help," Williamson says.
Thomas Hospital is a 150-bed acute care hospital with a 10-bed skilled unit within the hospital, an emergency department (ED), and a heart surgery program that opened in November 2002. Williamson is one of four division directors, all of whom make daily rounds as part of the hospital’s commitment to customer service, the hospital’s No. 1 goal for the past two years.
The administration has set a goal of scoring in the 95th percentile or better on patient satisfaction scores. When she makes rounds, Williamson encourages the patients to send in the customer satisfaction survey and asks them to let her know before they are discharged if there are ways the hospital could improve their experience as patients. "We believe our case management efforts can support the hospital’s overall success with customer service. When we improve patient care, it will ultimately increase patient satisfaction and physician satisfaction," she adds.
The case management team set out to gain physician buy-in from the outset. To help soften the approach and to encourage physicians to embrace the changes, the team decided to call the case managers "care coordinators."
"The primary purpose behind implementing an effective case management program is to improve patient care. Done well, case management can reduce a patient’s time in the hospital. It provides a single contact for patients, families, and physicians and identifies the patient’s needs early on so the patient and family can make more informed choices and decisions," Williamson adds.
To foster a close working relationship between physicians and care managers, each team is assigned to physicians, rather than by unit or specialty. The care coordinator handles all of the physician’s cases. The arrangement means that the physicians don’t have three or four different people calling them about cases. "While excellent patient care has been and will always be our main focus, developing good working relationships runs a close second. We have tried to bring care coordination on in a physician-friendly way. We hope the physicians see that we are here to help them and help their patients," she adds.
The system seems to be working. When word got out that Thomas Hospital was planning to make additional changes in its care coordination department, one physician made it a point to tell Williamson that he preferred to keep the care coordinator he had been working with because she understood how he practiced. "That same physician had been totally opposed to case management a year before. We had been working really hard to get physician buy-in. Getting support from this physician was a real success for all of us," she says.
Each morning, care coordinators generate a census and identify their patient population for the day. They retrieve physician orders that might need immediate attention and meet with patients and families to identify goals and anticipate discharge needs. The team conducts chart reviews throughout the day for utilization review.
Discharge planning begins on admission, Williamson says. "Although some patients may not require intervention, all cases are reviewed and followed. Some patients may be admitted and discharged without actually being seen or interviewed by a care coordinator."
The redesign process has not been an easy one, she says. The administration made the decision to make all the positions full time, eliminating many part-time positions that existed before the redesign. "Our model continues to evolve as all parties go through a learning process."
The hospital recently added a dedicated care coordinator for the outpatient program and the ED and created a new care coordination position to cover weekends. "The focus of our case management is on the patient and providing cost-effective, quality health care. As long as we keep this focus, the implementation will be successful," Williamson says.
Before Thomas Hospital in Fairhope, AL, redesigned its case management program, nurses from two separate departments social services and utilization review performed case management-type functions. In 2002, the hospital hired a division director to redesign its case management program and oversee the social work, discharge planning, and utilization review functions.
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