Should case managers absorb UR, discharge planning?
Answer may depend on whether your program is clinically based
To streamline their functions in today’s cost-conscious hospitals, some case managers say they have expanded their roles to include utilization review (UR) and discharge planning. Such a move makes sense, they say, especially in institutions where case management isn’t entirely clinical. But in hospitals with strictly clinical case management programs, combining case management, UR, and discharge planning may be more difficult, especially if case managers already carry heavy caseloads.
At St. Mary’s Health Center in Jefferson City, MO, case management has been UR/discharge plan-based for more than a year, says Virginia Irvin, RN, MN, CPHQ, manager of care management. She says that like most hospitals, the hospital has had a "sudden influx of managed care" contracts. She and her colleagues looked for a way to consolidate some of their duties to avoid duplication of effort. And, she’s not alone. According to responses to the 1996 Hospital Case Management Reader Survey, case management jobs have changed significantlyin the past year. A number of readers indicated they were working under more managed care contracts and had merged such areas as social services, utilization review, discharge planning, and even admissions into the case management process.
"We wanted to change the role of the traditional utilization review person who simply looked at records, made phone calls to insurance companies, and had no contact with patients," Irvin explains. "The social service department here did all the discharge planning. They set up all the home health, nursing home placement, and durable medical equipment. This department has now evolved to contain those two different disciplines so we’d have a more proactive role not only in managed care, but in whatever else comes down the pike." (See the box, above, for some of her tips for getting started.)
Aljune Lee, RNC, case manager in the behavioral health adult unit at Winchester (VA) Medical Center, is part of a pilot project that includes UR in case management. She says before the project was started, she was the only inpatient case manager for psychiatric patients. She performed consultation and education duties for case managers in other areas of the hospital, as well.
"Through statistics and changing times, we were able to identify that there was a need to also increase case management to include adolescent patients and start to do beyond-the-walls’ nursing case management for some of our more chronic patients who didn’t have a good track record at the local community service board," she says.
She says the hospital also wanted to offer services to newly diagnosed patients who required home health care after discharge. The facility then started a day-treatment program for patients that included three nurse case managers. The case managers are part of a "treatment team" consisting of case managers, social workers, therapists, recreational therapists, physicians, and nursing staff.
"We meet with the patient or [his or her] significant other to identify areas of concern as far as what brought the person into the hospital," she says. "We start to pull together the treatment plan."
At that point, case managers work with nursing staff to move the patient through the system.
"Before we went to case management with a UR component on our unit here, we had a utilization review nurse," says Lee. "At times, we were not really included in the actual dollar amount [of insurance coverage] the patient had. She would just tell us how many days the patient had based on what the insurance company said."
Now, there is an actual "intake department" of nurses who get insurance information during admission. They also verify benefits and give that information to Lee, who speaks with the insurance company about the patient’s discharge plan.
"Then based on that, we have to negotiate ongoing days as far as medical necessity as for stay here," Lee says. "The way I feel utilization review is working for us is . . . we’re getting more days authorized from the insurance company. As a case manager with a UR component, we know upfront how much difficulty we’re going to have with this insurance company or its doctor reviewer."
Nevertheless, setting up new systems that include other disciplines isn’t without pitfalls. At St. Mary’s Hospital, UR nurses weren’t used to performing social work functions, and discharge planners weren’t used to providing clinical, hands-on care, Irvin notes. She says cross training was necessary before their functions could be combined.
"We wanted to be able to function at the minimum level of the other profession, but we always had both disciplines on call, just in case," Irvin says. "If it became a matter that required the expertise of [someone] in another discipline, that person would be called."
For example, social workers had some understanding of medical terminology already, but didn’t always know about clinical conditions for admitting patients, since their training had focused mainly on discharging patients. Admission was an area that required extensive cross-training between nurses and social workers, Irvin notes.
"We talked to them about what the admission criteria are, and why a patient would be a regular admission over an observation stay," she says.
Conversely, social workers had been responsible for obtaining medical equipment for patients being discharged, such as pediatric respiratory nebulizers. UR nurses were unfamiliar with how to order medical equipment and home services; social workers explained that process to them. They also created a log book on how to obtain equipment through specific providers. But there are some areas that still require special expertise.
"The nurses can certainly do most of the discharge planning, but they aren’t social workers," says Irvin. "We do the initial screening, but anything that [requires] social work expertise, we move over real quick.
"If your case management function is a utilization/discharge planning approach as opposed to a clinical, hands-on, caregiver, nurse case manager approach, this is the way to go," she adds.
But for hospitals that use a more clinical approach, combining UR and discharge planning may not be as feasible, says Lisa Zerull, RN, MSN, program manager for case management at Winchester Medical Center. Although she says the pilot project to combine UR and case management in the behavioral health area appears to be working well, Zerull says she isn’t sure the same tactics would work on a more widespread basis.
"Because of our mission and the populations we serve, the nurse case management role in our organization needs to stay clinically focused, [without] the clerical [aspect] of finding a bed in a nursing home or talking to a payer at Blue Cross/Blue Shield," she explains. "They need to be available for the staff."
In addition, having case managers take over UR would be far too time-consuming, says Zerull.
"If you want to maintain a clinical aspect of the case management role, you really need to look at workload and caseload to determine whether it’s even feasible to combine UR, social work, and nurse case management the whole nine yards," she says. "What I’m finding is you can’t just add more job responsibilities to an existing position and expect it to flow well."
Zerull estimates that if UR became part of the case manager’s job, the typical caseload would have to be decreased by half from 20 patients to 10.
"Our smaller units are 20 beds, so you’re adding another person," she says. "Then, [there is the concern that] there may be a loss of communication or confusion as to who to talk to about what. We’re still wrestling with this."
But at some hospitals, UR functions are being included in new clinical case management roles. Mindy Shikiar, RN, MBA, MSN, ABQAURP, assistant administrator of clinical operations at Vencor Hospital in Fort Lauderdale, FL, says that in her previous job as director of quality management at Broward General Medical Center, also in Fort Lauderdale, the position of UR nurse was eliminated when restructuring occurred, and acute care case manager positions were created two years ago.
"We integrated the roles," she explains. "In my opinion, utilization review is a function that came out of DRGs in the 1980s, and that’s why that position was created. Case management is really a result of managed care in the 90s and the need to directly interact with patients, physicians, insurance companies, and be the liaison [between them]."
At Broward, as part of the patient re-engineering task force called the "architects of change," says Shikiar the decision was made to recreate the UR nurses’ positions, and the social work department was downsized. At the same time, the acute care case manager positions were being created.
"Because we had a patient-focused care model, we included social workers, utilization review nurses, and patient-care coordinators in the job development," Shikiar says. "There was a lot of anxiety with the utilization review staff, because they all had to re-apply for their jobs. But there was a lot of support for them from us and from human resources. We didn’t just let them go we placed them in other positions."
The social workers went from doing all the discharge planning to arranging only difficult situations, such as nursing home placement.
"The outcome of the restructuring has not only decreased length of stay and improved coordination of care, but job satisfaction is high among the new acute care case managers," says Shikiar.
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