NJ hospital gives internal merger second chance
Case management functions streamlined
Re-engineering case management was one of the key projects a New Jersey hospital conducted in an eight-month process of restructuring the entire facility to better streamline patient care. The hospital saved $850,000 in one year as a result of the changes.
By merging its two general medical units into a single unit, leaders at the 499-bed Jersey Shore Medical Center say they hope to be better prepared for an anticipated increase in managed care contracts in their area. The first effort at redesign, however, was not successful.
Jersey Shore Medical Center first implemented a service line-based case management system 18 months ago and quickly retreated. The service line-based case managers were responsible for following patients' care throughout their stay within a single service line of care, explains Richard Hader, RN, PhD, senior director of inpatient clinical services at the Neptune, NJ, facility. The reason that system didn't work? "There was no accountability and no clear delineation of duties between the utilization review nurses, the social workers, the bedside nurses, and the case managers. We added the case managers in on top of everything else, without looking at the entire system. They were responsible for doing everything, and what happened was nothing was done effectively," explains Hader.
The hospital began its original restructuring process by combining two general 35-bed medical units. As part of that process, three goals were set for the facility in which the new case management system played an integral part:
* Ensure that the hospital would be a strong player in a growing management care environment.
* Provide equal or greater customer satisfaction at a significantly reduced cost.
* Provide equal or greater clinical quality at a significantly reduced cost.
Jersey Shore had to devise a system that would ensure it would be a player in the expanding managed care environment and would remain competitive, Hader says.
The hospital's growth in managed care contracts appears to reflect that the changes are paying off. In the last quarter of 1994, 6% of Jersey Shore's revenue came from managed care payers. That jumped to 15% by the end of 1995. Hader predicts a 30% share for managed care revenue by the end of this year.
Taking a unit-based approach
"The whole new system is designed to provide accountability at each unit level. Our case managers now report to the nurse manager of the unit, and the nurse manager is responsible for the product or the service that's being delivered," explains Hader.
Specifically, case managers are responsible for monitoring lengths of stay (LOS), costs, and discharge planning activities. The traditional case management duty of variance collection and analysis now is performed by medical data specialists and the outcomes management department.
In finding the right staff to fill the newly focused case management positions, Hader decided to start from scratch. "Some of these case managers came from the social work department. We've actually upsized case management, although not all [former case managers] that were in this centralized approach are still here. They had to apply for these positions. This person needed to be a registered nurse.
"We had originally required [the position] to be a master's prepared position, and then when we did this restructuring, we decided not to require that. This wasn't for cost-savings because the salaries remained the same. What we really wanted were people who knew what was going on clinically on that unit and were able to work with the doctors, physical therapy, and respiratory therapy to get that patient out of the system as quickly as possible," explains Hader. Experience was more important for the position than advanced education.
The old system was ineffective at discharging patients because it did not allow case managers to effectively monitor a patient's recovery. Service-based case managers covered too many different units and were unable to build the necessary rapport with the physicians or specific nursing staffs, says Hader.
The new system, which officially started in January 1996, consists of 10 unit-based case managers who are responsible for patient care on individual units. They follow the patients by using critical pathways and report to nurse managers on the units, explains Hader.
"With a changed role, I now have accountability to a unit, and will monitor care across the continuum, which I'm looking forward to," explains Loretta Ninivaggi, RNC, case manager, one of the hospital's former nurse managers re-engineered into an orthopedic case management position.
"My new role will be ensuring patients get in and get out as quickly and efficiently as possible with the things they need to be able to be at home. I'm going to be more clinical, and I'm going to like that piece because I'm going to be with the patient, whereas before, I was more staff and problem-solving oriented," explains Ninivaggi.
Determining how and who would be involved in the role switch was handled as fairly as possible. "I am the only nurse manager re-engineered into case management," explains Ninivaggi. "The other nurse manager and myself worked on the re-engineering process, and we came up with a plan that called for one [nurse] manager to handle two floors. We knew one of us would be out," continues Ninivaggi.
The importance of training
As with any new program, Jersey Shore's internal merger required significant staff education. A comprehensive training program was put into place eight months before the restructuring process began. "We worked with consultants from the Center for Case Management in Boston," says Hader.
The initial training for the new case managers began with weekly meetings with the consultants in early 1994. Next, case managers discussed individual unit plans in meetings with an in-house support committee.
The case managers then met with a group of their own unit staff who began helping them develop a case management plan. "After a while, the staff almost got out of our training because we got to the point where you had to find out certain facts, such as how many lab sticks are done on our unit, or how many chest X-rays," recalls Ninivaggi.
Throughout the summer, more meetings commenced for all staff along with the president or vice president of the hospital about the restructure in general. Finally, formal classes started in September, which helped the case managers prepare for the new job.
Decision support staff add CM duties
Case managers are better equipped to spot potential patient problems and analyze care with the assistance of the new outcomes management department. In addition to a manager for the new outcomes management department, the hospital created three new analyst positions:
* financial analyst -- works with the physician on-line management system, pulls relevant data and any other data that help the hospital benchmark against other hospitals;
* clinical analyst -- a master's-prepared nurse who provides clinical expertise for individual cases. "For example, we use Inocor, an expensive anatrophic drug, a lot in the surgical intensive care unit. She can kick certain information out and say, 'We know there's another product on the market that can do the same thing for less cost,'" Hader says.
* quality outcomes analyst -- reviews benchmark data from other institutions to ensure the quality assurance program remains in line with available data from other institutions and identifies areas to implement process improvement programs.
The financial analyst relays what the current LOS is for specific patient groups, and what LOS criteria need to be met to compete with national standards, explains Ninivaggi. "For example, if we have to get a pneumonia patient out in four days instead of our current nine days, then our target for this year would be six days, and then hopefully down the road get it down to four."
Although Hader says he felt it was important to have the case managers work with the outcomes team, he did not want them directly in this unit, reporting to the outcomes manager. "We felt that it was very important to have that accountability at the unit level, so the case managers don't report to [the outcomes manager], but Loretta's helping to bring this whole program together," says Hader.
In addition to working with the data analysts, the case managers also work closely with critical pathway teams, led by a nurse manager and often a physician leader. Clinical nurse specialists also work on these teams, which are responsible for deciding which critical pathways need to be used, who's responsible for developing them, and which critical pathways need to be developed or refined. Currently, six critical pathways are in use.
Case managers at Jersey Shore no longer collect or analyze pathway variance data. Instead, the case managers only document the variances, explains Hader.
Variance collection is done by medical data specialists, who comprise the former medical records department. The internal merger also led to a name change for the medical records department to the health information management department. The medical data specialists are coders, abstractors, or RNs. The medical data specialists submit the variances to the outcomes management analysts, who then analyze the variances and suggest corrective actions.
"The case managers will continue to follow the paths and be responsible for seeing that the patients remain on the path or justifying reasons why patients are not following the path," Hader says.
"I see the case managers eventually becoming responsible for the products or a group of products, just like the nurse managers are now. But we needed to install some accountability. We needed to be able to go to our step-down cardiac surgery unit, for example, and say, 'When these patients are on the unit six days and they need to be out in three, what's going on?' We needed to start from scratch and really build some of those relationships between departments and with physicians," explains Hader.
"The key element here is that one person cannot do everything. It must be a system, and that's why we broke it out into this system, such as having the variance collection done by the medical data specialists," adds Hader.
Ninivaggi agrees, although she admits she initially faced her switch unenthusiastically. "When this all happened, the hospital sponsored a job fair. When Rich Hader told me I was the one who was not going to be here, I took a job in a different part of the hospital. Then, what ended up happening about one month later was he asked me to come on as a case manager." *
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