Collaboration fills missing piece of CM puzzle
New role for case managers takes additional skills
By incorporating the key functions of case management, quality improvement, utilization management, and patient care, The Ohio State University Medical Center in Columbus has created a new breed of case manager: the patient care resource manager (PCRM), charged with improving quality and patient care across the continuum.
Since its inception two years ago, the program has resulted in a 16% decline in length of stay across the board, as well as a sharp decline in claim denials.
"We don't have any raw numbers on exactly how much claim denials have decreased, because we're still tracking data from last year. Prior to that, there was no tracking mechanism, so we don't have a comparison," explains Carol A. Phillips, RN, MHA, one of three directors of patient care resource management. "However, the services that are managed by PCRMs have a zero denial rate. The services that don't have a PCRM aren't anywhere near that."
Getting to such noticeable results first required the creation of the PCRM position itself. The job description for the PCRM is a true melting pot of responsibilities. "We incorporated multiple disciplines in this job and framed it in a way that's very unique," Phillips says. Although case management is a key component of the PCRMs' jobs, that is not their exclusive responsibility.
Leading up to the creation of this position were several concerns occurring simultaneously, explains Phillips. "We were concerned about the experiences of our house staff. We wanted to make sure that it was a good experience so that we could attract good residents and interns. So, we decided to have a clinical teaching task force conduct a survey and talk to people in terms of their [work] experiences."
Hospital, physicians agree on finances
The task force recommended the hospital hire professionals with both clerical and clinical skills who would be helpful to the house staff. "We also knew we needed to provide better customer service to our payers and patients. We needed to become more efficient and decrease fragmentation of services. We knew we needed to do some sort of role consolidation," Phillips says.
Therefore, the hospital and physician groups committed to a financial agreement to invest in that staff together. "The dollar amount doesn't mean much, but rather the fact that we were willing to do this as a team was what was important. We received tremendous support from both the medical staff leadership and the hospital leadership," Phillips notes. (To see how case managers work with the physician groups, see the related article, p. 60.)
To win that support, the program was presented in a way that made it clear that this new position was a benefit to both sides, thereby enticing the physicians to request the services of the PCRMs. "We didn't want to go out and try to push them into anybody's practice," notes Phillips.
Prior to the development of the PCRMs, the facility did not have case management at all. "We had nurses who did utilization review, nurses who did continuity of care, and social workers," Phillips says. Although the facility still employs social workers, the number has been reduced because the discharge planning function is now performed by the PCRMs, leaving the social workers to do the psychosocial intervention.
The scope of the PCRM job is divided into four main areas, and each job is tailored to meet the needs of the specialty in which the PCRM works. To aid the PCRMs in time management, they follow a range-of-time guide for each area. Within those set time frames, they designate their time as service needs dictate.
The primary areas they are responsible for include the following:
* Care facilitation -- 20% to 40% of time.
This responsibility calls for the PCRMs to orchestrate patient care among multiple delivery sites and among multiple caregivers, which may range from preadmission testing to post-discharge coordination of care in both inpatient and outpatient settings.
* Fiscal accountability -- 20% to 40% of time.
This area calls for the PCRMs to coordinate procedures and policies between payers, providers, and patients, and to serve as the primary patient information resource for payers. Through this role, the PCRMs anticipate and troubleshoot claim and reimbursement problems. They also participate in initiatives to reduce costs and optimize resource utilization.
* Quality improvement -- 20% to 30% of time.
Through this role, the PCRMs monitor quality and outcomes using hospital and medical department indicators, which often are included on practice guidelines. "The PCRMs are instrumental in working with physicians to develop the guidelines, and they serve on quality improvement teams and value enhancement teams," Phillips adds.
* Patient care -- 10% to 40% of time.
The PCRMs collaborate with physicians and other health care workers to provide comprehensive health assessment, treatment, and follow-up evaluation for patients. That includes health risk appraisal, health promotion, and clinical research.
The PCRMs set their own schedules according to the needs of the service, often working more than 40 hours per week, Phillips says. Typical patient caseloads average 15 patients for each PCRM, she adds.
The number of budgeted PCRMs for a service is determined by patient volume, patient needs, and specific service expectations, continues Phillips. Utilization review and discharge planning functions on services without a PCRM are provided by a discharge planning nurse specialist and, as needed, by temporary staff.
The PCRMs work across multiple sites, which include the medical center, a cancer center, a neuropsychological facility, and a rehab facility.
The PCRMs stepped in to address the needs of patient care by helping to expedite the time between diagnosis and admission, and provide continuity within that time frame.
For example, one service's physicians expressed concern about their referral base. "They didn't feel that they were providing the best customer service that they could," Phillips says. The solution was to have the PCRMs develop a physician referral packet containing information that they could send to the referral physician within a short time period.
"Still other physicians said, 'What I need is a physician extender -- someone who can help me see patients.' In those cases, we designed more of a nurse practitioner role and hired people to accommodate those needs," Phillips says.
Care facilitation key CM component
Phillips stresses that although the PCRM role is not case management in the traditional sense, many of their responsibilities call for keen case management skills. The care facilitation piece is the PCRMs' key case management responsibility, but was tailored to more effectively meet the hospital's and physicians' specific needs. Even though the PCRMs are responsible for each patient's continuum of care, they don't always follow the patient through his or her care. For example, if a cardiology patient needs a coronary artery bypass graft, the cardiology PCRM doesn't go with the patient through that treatment, he or she transfers the case to the cardiovascular PCRM, Phillips explains.
"The PCRM who discharges the patient and follows the patient is typically the one who has the patient on the last part of his hospitalization. A lot of our patients are referred from other communities, so we send them back to the community and make sure that they've got follow-up there."
Like traditional case managers, the PCRMs develop and use critical pathways. They document on the pathways themselves and take a "systemwide approach, which begins with the physician. Our pathways are physician-driven. The PCRMs participate in [pathway] development along with the physicians," Phillips says.
The PCRMs also develop outcomes measures for the pathways and assist the staff in ensuring that the monitoring gets done.
Variance tracking, which still is being fine-tuned, will become part of the quality initiative. Phillips explains, however, that this area still is evolving and data collection for some pathways is just beginning. "Several [pathways] have been developed, and some have been implemented, but we haven't gotten to the point where we're actually getting results back."
Perhaps one of the biggest benefits of the program is one that is not quantifiable, Phillips says. The PCRM has become "the bridge or the glue between the hospital and the physician practices. We've been able to establish a route of communication between those two areas that's never been there before.
"The physicians trust the PCRM because they are part of their practice. We trust them because they are part of our practice. We try to educate the PCRMs continuously about hospital initiatives, strategic objectives, the health care environment, and contract changes. They, in turn, then can educate the physicians and help them position their practices for success in the environment or help them understand what's ahead."
Re-engineering needed for success
The creation of the PCRM role did, however, create some upheaval in the hospital's existing staff. Unfortunately, not all staff were re-engineered into this new role.
"We identified what we felt were the qualities that would allow this person to succeed in this role. Because this role is extremely autonomous and self-directed, we felt we needed people who had the caliber and the drive to hit the ground running," Phillips says.
The hospital-physician leaders didn't have a lot of time to get things going in terms of creativity and resource management, so the hospital looked for people who already had those traits, notes Phillips.
All staff, however, were encouraged to apply for the new position. So far, only one person from outside the hospital has been hired to fill a PCRM slot, but many other existing staff were shifted to other positions in the hospital.
"We're committed to this position. If we would have given [the physicians] someone who was a nice person but didn't have that pizzazz, it would have been a huge mistake and the downfall of the program, so we weren't willing to do that," Phillips says.
Phillips still has seven PCRM service slots that she needs to fill to complete the hiring process.
What has taken Phillips and her colleagues nearly two years to complete and fine-tune could now be done in about six months, says Phillips. "With the knowledge that we've gained, if we were to start this program from scratch now, it would probably take six months to sell the program, ensure that everybody understood it, and establish the physician leadership." *
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