RNs make great case managers
Experienced nurses handle chart reviews
Moving utilization review (UR) staff into case manager roles is not always a smooth transition, many hospitals have discovered. But a Pennsylvania hospital has negotiated the shift fairly simply by selecting UR staffers with strong nursing backgrounds and experience in chart reviews and quality tracking.
When the 110-bed Marian Community Hospital in Carbondale, PA, recently launched its clinical pathway-based case management program, it assigned case management duties to its four UR nurses rather than hire outside case nurse specialists (CNS), says Mary Ann Salak, RN, quality management director at Marian.
The UR nurses/case managers all brought extensive clinical backgrounds to their jobs, as well as experience in performing chart reviews, which was part of their regular UR chores, says Norma Nocilla, RN, CPHQ, performance improvement director at Marian. As a result, they required no special training to function as case managers, Salak says.
"We [RNs] are used to doing preadmission screens, dealing with insurance denials or appeals, and finding different levels of care such as referring patients to social workers," she explains.
Besides, while the hospital needed case managers to improve the use and outcomes of its clinical pathways, administrators at the small facility could not afford to hire clinical nurse specialists, who earn $30,000 to $50,000 to start vs. the average $34,000 salary for an RN, adds Nocilla.
No place for beginners
Since Marian’s UR nurses always tracked the quality aspects of patient care, such as readmission and complication rates, switching to a case management function did not require a giant leap in thought processes, Nocilla says. "For hospitals that have separate quality assurance and UR functions, it might be a harder switch," she says. "All my RN reviewers have multiple experience as supervisors and managers, years of nursing experience, and already knew what was expected from utilization."
Nocilla advises other hospitals to phase in the job change for UR nurses with little quality background. The mindset from UR to case management can be abrupt unless UR nurses are allowed to take on quality of care tasks along with their UR duties, she says.
Salak advises also selecting staff that will be proactive in patient management and working with other departments. At Marian, UR/ nurse case managers interact daily with other providers involved in each patient’s case, including social workers, other nurses, and physicians. "All clinical disciplines are involved in weekly discharge planning meetings, and every day the staff nurses, case managers, and social workers talk about the cases concurrently," Salak explains.
Duties include performing daily, concurrent chart reviews of patients on the hospital’s four high-cost, high-length of stay (LOS) clinical pathways they manage: pneumonia/COPD, congestive heart failure (CHF), acute myocardial infarction, and total joint procedures. (See sample pathway, p. 134.)
They also handle preadmission screening when a pathway begins prior to admission and collect process and outcome indicators as part of the case management function.
Process indicators identify treatment standards, such as when a medication should be started. Outcome indicators track a patient’s progress toward recuperation, such as whether a pneumonia patient has clear breathing sounds or is able to perform simple functions such as eating and toileting without shortness of breath by time of discharge, says Nocilla.
Concurrent review solves problems fast
The UR nurse/case managers head off potential problems by carefully checking patient charts each day to identify when an incident such as a delay in scheduling a test occurs. Concurrent review immediately alerts staff when there is a delay or problem, Salak says.
"The key is to be proactive," Salak advises. "Don’t tell me something after you can’t do anything about it. When you’re doing concurrent review, you have the opportunity to correct the patient’s care when you see a deficiency."
The UR nurse/case managers also ensure resources are used wisely. Daily chart reviews enable them to uncover when tests have been ordered while the patient is in the hospital but for which Medicare will not pay because it’s not part of the diagnosis and can be done on an outpatient basis. "For instance, if a pneumonia patient was on the floor and someone saw a mammogram was ordered, they would alert staff to see if it could be done outpatient later," Salak says.
With pathway-based case management only underway since June 1996, it’s still too early to determine whether LOS and costs in the four diagnosis-related groups are down, Salak and Nocilla say. But the case managers continue tracking variances each day, and the use of clinical pathways is rising. While in the past only the surgical specialists used the paths consistently, medical staff are now also using them with growing frequency, Nocilla says.
"Clinical paths are the whole basis for our case management," Nocilla says. "The case managers have to be experts on the pathway because everyone will look to them for the answers."
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content