Case management program is a home-grown success
Nurse practitioners focus on discharge planning
Developing a case management program at Mission St. Joseph’s Health System essentially from scratch highlights how nurses can work together as leaders to effect change and improve patient care.
For years, nurse managers in the neonatal intensive care unit (NICU) at the Asheville, NC-based hospital worried about their length-of-stay numbers. Between 1994 and 1995, the average length of stay (ALOS) for their most delicate preemies under DRG 386 ranged around 126 days.
Administrators of the 35-bed unit said that number was too high. The solution lay in something that at the time was largely untried in critical care but was being discussed with growing respect in health care. The tool was called case management, and it was achieving results in other acute care departments around the country.
But the nursing staff at Mission St. Joseph’s were working at a disadvantage. Although they generally understood case management principles from attending conferences and seminars, they didn’t know exactly how to implement a program.
Everyone brought something to the task
For one, the staff weren’t sure whether they should try to match the national average on ALOS, if one even existed, or set inflexible targets for reduction. But if ALOS could be lowered by a certain amount, they could thereby reduce per-case charges.
Coincidentally, hospital administrators were looking for ways to cut costs, delve into clinical pathways, and operate the 800-bed institution more efficiently. Impetus was added for the department to look for solutions, recalls Terri J. Forsyth, RN, MSN, CPNP, a former neonatal case manager at Mission St. Joseph’s who is now at Children’s Hospital of the King’s Daughters in Norfolk, VA.
After nearly two years of hard work beginning in 1993, length of stay in NICU dropped significantly, falling to 105 days in 1996 from 126 in 1995. Charges per case also fell by a surprising 24% to $186,000 from $245,000 in the same period, according to figures supplied by the hospital.
Much of the credit goes to unit director Ginny Raviotta, RNC, MN, and clinical specialist Anne Ramirez, RNC, MSN, who laid the groundwork for the project and "really got the entire nursing staff’s acceptance," Forsyth recalls. But everyone brought something to the project. "We were all determined to make it work."
In 1994, one of the nurses’ goals was to "establish expected outcomes that would allow us to measure the unit’s effectiveness," according to L. Ann Maney, RN, CNNP, a nurse practitioner who, along with Forsyth, was hired to help with the project’s implementation.
Instead of looking at the problem from the point of admission, which would have been the logical place to start in a med-surg department, the case management team decided to focus on the end stage of the patient stay by concentrating on discharge planning.
They wanted to effect changes when the pre-term baby was out of immediate danger and considered to be in an "intermediate convalescent stage," which was about one to two weeks before discharge. Ironically, this group of patients was the most vulnerable to a lengthy hospitalization primarily because their management at the time was left to nurse practitioners, and there weren’t enough NPs to ensure optimum discharge planning, Maney says.
At the beginning, the team adopted five goals taken from earlier groundbreaking work:
1. Discharge patients within an appropriate length of stay.
2. Establish expected outcomes.
3. Promote collaborative practice, coordinated care, and continuity of care.
4. Use resources appropriately.
5. Promote nurses’ professional development and satisfaction.1
In effect, the plan was to achieve appropriate discharge and prevent readmission, Maney says.
A key ingredient in the case management model was the development of a clinical path, an interdisciplinary plan of care that would outline patient problems, health care interventions, and expected outcomes within an anticipated time frame.2
Another factor was the assignment of case management duties to NPs. "Rather than have the hospital case management department oversee the task, it was felt that nurses should do it," says Forsyth.
The year before, in 1993, Raviotta and Ramirez formed a work group consisting of a bedside nurse, clinical specialist, neonatologist, nurse manager, pharmacist, nutritionist, social worker, and outreach coordinator, among others. The group, informally designated the clinical path team, identified three areas for improvement: the unit’s documentation, parental education (in preparation for patient discharge), and the creation of practice consistency.
The unit’s documentation had to be streamlined and simplified. "There was paperwork everywhere. We had documents for this and documents for that. And in parental teaching, we thought we could do a lot more. The work with parents was usually left for last and took place only a few days before discharge," Maney says.
Patiently, the team began to pull together information about forming clinical paths and case management programs, which they gathered at conferences and from their own brainstorming. After extensive patient chart reviews and discussions within the work group, the team reached two conclusions.
In addition to focusing on the end rather than the beginning of the hospital stay, the team concluded that efficient discharge planning was hampered by the different practice methods of the NICU’s three neonatologists on staff at the time. By meeting weekly with the physicians, the team was able to draft a clinical path, "The Convalescent Discharge Planning Path for the Stable Pre-Term Infant>1,500 Grams." (See form inserted in this issue.)
The path, which has undergone several changes, was designed to function like an interdisciplinary plan of care. The babies chosen for case management had to meet the following categories:
1. Weight of >1,500 g and stable physiologically in room air.
2. Age range from eight weeks born at 24 weeks of gestation with a birth weight of less than 750 g to two days born at 35 weeks of gestation and weighing more than 2,000 g at birth.
Common goals involving daily care were agreed upon and followed to avoid variances in care.
During daily rounds, nurse case managers would make assessments and complete a written progress report using a problem list and plan-of-care format. The assessment would be reviewed with a bedside nurse and the attending physician.
The case manager would also write orders to ensure the baby’s progress on the path. One of the benefits of following the path was that it consolidated the paperwork and eliminated the need for separate nurse care plans, kardexes, discharge sheets, and teaching sheets, Maney explains.
The manager would also work with the patient’s family on the path, including current problems and discharge plans. During extremely busy periods in the NICU, case managers had to back up the bedside nurses.
The paths would be examined daily, and staff members would address variances to ensure consistency of care. At weekly meetings, the staff also reached decisions on babies who ultimately did not meet the path’s criteria or those who should be added because they might benefit from the protocol.
In addition, case managers closely monitored pertinent data on the population, including length of stay, per case charges, readmission rates, quality improvements, treatment variance, mortality, and morbidity to study changes in response to the path.
"We received the support of the hospital’s case management department, but they pretty much let us run with it," recalls Forsyth. But department committees including quality improvement and nursing research pitched in with guidance. Revisions to the path and outcomes assessments went on for weeks.2
Careful attention was paid to discharging the babies only when it was deemed appropriate, Maney says.
When case managers submitted their findings for publication in 1997, ALOS was down sharply and per case charges showed that case management could be cost effective.
However, though promising, the results were qualified by the fact that case management wasn’t implemented until April 1995. The effects on measured length of stay and per-case charges were not realized until later that year. Therefore, the comparison between 1996 and 1995 did not measure two full years.
In addition, the unit did not measure outcomes or readmission rates. And at the time, hospital administration reportedly indicated that results following case management could have been better, Forsyth says reluctantly. Nonetheless, Maney says, the team demonstrated that case management in the NICU does work if properly implemented.
In fact, the effort was considerable given the nature of neonatal intensive care, a view supported by others in hospital case management.
"In some settings, case management is extremely difficult to pull off," says veteran nurse Deborah S. Smith, RN, MN, a case management expert and executive vice president of American Medical Systems, a health care management consulting firm in Los Angeles.
"Whenever the [patient] cases are complex and long-term, case management shines. But it doesn’t get easier."
That fact, which has become well-known to nurses at Mission St. Joseph’s, has spurred its nurse case managers to continue their efforts in hopes of getting better. The unit is reworking the path all the time. "It’s a work in progress," a confident Maney concludes.
References
1. Zander K, Etheridge ML, Bower KA. Nursing Case Management: Blueprints for Transformation. Waban, Massachusetts: Winslow; 1987.
2. Forsyth TJ, Maney LA, Ramirez A, et al. Nursing case management in the NICU: Enhanced coordination for discharge planning. Neonatal Netw 1998; 17:23-34.
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