Case managers put a new face on subacute care
Case managers to improve efficiency, cut costs
As the distinctions between acute and long-term care become blurred, subacute care likely will play a more integrated role in health care delivery, according to experts in the field.
Subacute care is growing rapidly as a result of improvements in emergency medical care and technology, decreased lengths of stay, population growth, and changes in Medicare rules, says Dana Carr, MS, BSN, RN, director of case management at Hebrew Hospital Home Inc. in Bronx, NY.
And while more patients are entering subacute facilities, the function of case management within those systems has become increasingly important to the overall continuum of care.
The case manager’s role in subacute care is multifunctional, says Carr, who implemented a three-person case management program 18 months ago at Hebrew Hospital, a 480-bed nonprofit skilled nursing facility (SNF). At Hebrew Hospital, the case manager coordinates the flow of patients through the facility and, in collaboration with the interdisciplinary team, works to optimize patient outcomes at the lowest possible cost. The case manager also acts as a liaison with entities such as the referral sources, the patient and family, the managed care organization, and the community-based physician.
"If implemented at the right point on the continuum, case management can accomplish all of those goals as well as enhance patient satisfaction through its advocacy role," says Carr.
In order to survive challenges posed by the Balanced Budget Act of 1997, SNFs are being forced to adopt creative and cost-effective ways of operating. Some strategies involve develop-ing protocols that address education, quality, and teamwork, and evaluating the organiza-tion’s goals, mission, philosophy, and vision. Also, properly managing resources, case mix, and associated costs is crucial to success under cost containment, Carr says.
Case management will become even more important to subacute facilities as the number of middle-aged consumers in need of care grows. Also, there is an attitude among many managed care companies that subacute care should replace continued hospital stays or, in some cases, any hospital stay at all.
The national market for subacute care is projected to expand rapidly. Regardless, budget constraints have forced facilities to tighten their belts and explore ways of saving money.
Case management necessary for success
Part of the goal on a subacute level is to ensure that services are not being duplicated. Eliminating duplication, in turn, promotes efficiency and cost effectiveness.
And while the definition of case management can vary from facility to facility, Carr says at Hebrew Hospital it is not simply a marketing function of "going and bringing patients into the nursing home." Rather, she says the case managers track patients across several levels of care, and the system is designed to manage patients’ needs regardless of where care is being provided.
Subacute care can add seven to 25 days to a patient’s confinement in a facility, and during that time, delivery of care must be well-coordinated, efficacious, efficient, and cost-effective. "The process ideally begins when the referral document is received by the SNF," says Carr.
Maura Lyons, RN, BSN, a case manager at Hebrew Hospital Home, says upon receiving a referral, she visits with the patient and family to determine if Hebrew Hospital can meet the patient’s needs. "It’s extremely important that you screen the patient so that you can customize or individualize a treatment plan," she says. "That’s why it is important to have case managers in subacute care."
Lyons adds that much of her job involves education — of patients, family, and hospital staff. "People need to know what we do here. We have the whole continuum of care, and a patient is much better off being here than in the hospital."
In most acute care settings, patients are being discharged quicker and sicker. "As we enter the 21st century and the baby boomers approach old age, the way in which we care for our elderly will influence many aspects of life for all age groups in our society," Carr says.
Case managers will need to be patient advocates, providing follow-up services to determine whether the patient is continuing to receive appropriate care.
Lyons works as an advocate, splitting her time evenly between clinical and marketing duties. "Whenever you are doing anything in nursing, I believe you are marketing, in that you are relating to the patient, the family, the staff, and you are representing your facility. You really must see yourself as a representative of the facility with a focus on patient care, quality of care, and doing what is right for the patient and family," she says.
Hebrew Hospital implemented case management in January 1999, and since then, the SNF has increased its ability to care for patients in an environment where their reimbursement will no longer pay for acute care.
The department has allowed Hebrew Hospital to market its facility as having professional case managers on board who can coordinate care and act as a liaison with the acute care facility.
"In many cases, when patients leave the hospital they think of going home," says Carr. "They don’t think of going somewhere else for interim care before they go home. For us, it is really an opportunity to bring case management to that patient to initiate an education process, which says, You are not just going to a nursing home, and as a representative of the facility, it is my goal to get you through the system.’ Families and patients appreciate that. And a lot of times that is why patients prefer us."
And if the patient gets sick again and requires acute care, the case manager follows up with the hospital and re-evaluates the level of care. This will include an on-site assessment and conference with the acute-care team. These activities facilitate the patient’s return to subacute if that level of care continues to be required. "That’s a big part of it," Carr says. "Before we had case managers, we had to rely on the social worker in the hospital to say the patient is ready to come back [to the SNF]. Now we are able to better plan for care based on an on-site skilled professional assessment made by our own staff."
The move to case management requires a team approach. Therefore, key organizational players must come together and take an active role in the development, implementation, and transition process, according to Carr.
It is critical to the success of a program that all players are clear about the role and importance of case management in the organizational structure.
Since some departments likely will feel threatened by an RN taking on the role of case manager and its related activities, Carr says the role must be clearly defined so others, particularly members of the interdisciplinary team, can see the benefits.
"The role is a collaborative and consultative one, with a strong emphasis on clinical expertise and skilled assessment," she says.
For more information, contact:
Dana Carr, MS, BSN, RN, director of case management, Hebrew Hospital Home Inc., Bronx, NY. Telephone: (718) 239-6657.
Maura Lyons, RN, BSN, case manager, Hebrew Hospital Home Inc., Bronx, NY. Telephone: (718) 239-6650.
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