Integration trend gains steam: How to avoid pitfalls when disciplines merge
Make sure you’re doing it for the right reasons, experts warn
Across the country, hospitals large and small are cutting costs by collapsing every quality-related department they can find into case management. As a result, some case managers face steep learning curves simply to keep jobs they thought they knew inside and out. If this hasn’t happened at your institution yet, it probably will — and soon.
Whether integration is good or bad for a department and the patients it cares for depends on how and even why it’s being done. Clearly, the main motivation is money at most institutions. "People ask, do you truly need three people to do this job, or can you combine some of the roles?" says Christine S. Sytsma, RN, MSN, CCRN, a case manager in critical care at Winchester (VA) Medical Center, which is now in the process of integrating its case management department.
But if the decision to integrate is based solely on money, problems will inevitably arise, says Sue Erickson, RN, MPH, assistant hospital director at Vanderbilt University Hospital in Nashville, TN. "If you’re in an environment where people are trying to cut dollars and cut corners and think I’ll just pack all this work into only one role and get more bang for my buck,’ then you’re going to create tension between the different disciplines," she says. "Because [in that type of environment] somebody’s going to lose out and somebody’s going to win. And more often than not, the nurses will win, because people will perceive they’re the most generic player."
At Vanderbilt, where Erickson’s "triad" model has gained notoriety, decision makers decided early on to reassure players in all the affected disciplines that they were needed and valued in the new system. (See related story on Vanderbilt’s triad model, p. 3.) "Our people learned how to work together because there wasn’t the threat over them that somebody was going to win out," she says. "All the disciplines are equally valued in the team."
But money isn’t the only reason to explore integration, Sytsma notes. For example, she says, "How many people do patients need to interact with? Patients don’t like being subjected to three people asking the same question. They don’t like you to tell them that someone else is following up on something. So patient satisfaction, which depends on the timeliness and continuity of care delivery, is driving [integration] also."
For example, utilization review at Winchester is centralized, while social work is unit-based. "So we all have different reporting mechanisms," Sytsma says. "That makes it a little disjointed for us. The problem is that we overlap on some cases, so we’re tripping on each other. In order to address that, we’re considering a more centralized reporting mechanism so that there is a more collegial relationship among departments."
Continuous quality improvement also drives integration at some facilities, Sytsma says. She notes that physicians have always regarded utilization reviewers as "the cutters," while viewing clinical nurses as acting in the best interest of patients. By combining functions and having clinical case managers deal more with financial issues, quality improvement should become an easier proposition.
But Erickson cautions against adopting a model that unduly burdens clinical case managers with utilization management duties. "Early on, in the spirit of redesign, a lot of people thought that if they gave their discharge planners utilization management and gave utilization management people discharge planning, then they’ve effectively created case management," she says. "I have a strong bias against that model, because the work of utilization management is time-dependent. You have X number of reviews and you’ve got to get them in by the end of the day or you potentially will lose that day’s reimbursement. If the person who does that also has to case-manage — which to me means interfacing with the patient and family and coordinating with the medical team — then the case management responsibilities will seem time-deferrable. Because if push comes to shove, and you know that you have an absolute 5 p.m. deadline to get the reviews done, and you could let the discharge planning fly until tomorrow, that’s probably what you’ll do. To me, that model asks people to shift gears and prioritize not in the patient’s best interest."
Case managers play pivotal role
Case managers at University Hospital-University of Colorado Health Sciences Center in Denver are attempting to avoid such pitfalls as they adjust to sharing a cooperative relationship with the hospital’s Office of Clinical Practice (OCP). Far from creating conflicts, the arrangement, which came together in the summer of 1998, has helped give case managers a better sense of the role quality management and outcomes play in their everyday work, says Elaine Cohen, EdD, RN, director of case management and co-director of the OCP.
"The case manager really is the pivotal person to help implement the pathways and implement the research that has to be done," Cohen says. "But I think they’re getting a clear picture of how we’re all interrelated and how we have to partner collaboratively together to get done what we need to do."
Cohen notes that most of the OCP staff are nurses with an excellent clinical understanding in addition their computer and data skills. "So they’re wonderful in terms of helping to analyze the data we get off the critical pathways." In addition, the reformulated department has begun to look at quality-of-life indicators for patients on critical pathways, Cohen says. "They instituted a critical value plan, which encourages physicians to come on board and develop paths or algorithms to help look at cost-effectiveness and quality of care."
University Hospital’s basic model had been in place for three years. Six months ago, Cohen was hired to help the case management department and the OCP take the next steps by integrating more continuum-of-care pieces in the existing model. Cohen’s first step was to spend time one on one with all 40 members of her new team — a process that took about two months. On the basis of those discussions, she wrote a comprehensive development plan.
One of the first things Cohen did was look at developing the whole shared mission, vision, and strategic planning for the department. Next came a work complexity analysis to delineate the roles and functions of the case manager and the multidisciplinary groups. "The idea was to help the group meet the increasing demands of our organization through leadership and facilitation of our goals," Cohen says.
One purpose of the work complexity analysis is to find ways to standardize the case management process, she adds. "We have a lot of departments here that have care coordination and case management," she says. "We’re trying to matrix with some of these departments and standardize a lot of the methods, tools, and advance reports."
Additional development goals at University Hospital include:
• Integrating inpatient and outpatient service delivery.
"We’re looking at establishing new relationships and collaborations while enhancing our existing relationships with ambulatory services," Cohen says.
• Developing and implementing a continuum-of-care delivery service.
"We want to work on a model that’s very smooth and dynamic and that meets clients’ needs," she says. To promote continuity, the team is looking at doing work with admitting and information systems. Cohen also wants to increase exposure with different payer groups and establish better linkages with third-party payers.
• Develop and implement a multidisciplinary practice model.
We’ll be looking at how to retain a multidisciplinary approach with well-defined roles for team members, and what the different practice components of that are," Cohen says.
Administrators at Winchester Medical Center are still evaluating what sort of integration model to adopt. But Sytsma says the final product is likely to include a spiritual component. "Instead of a triangle with social work, utilization review, and case management, they’re looking at adding in ministry or clergy because we have parish nursing here in our facility," she says.
The parish nursing program also ties into Winchester’s commitment to community-based care. Through the program, nurses offer their services to a given church and offer health screening and home visits to patients.
Still, Sytsma contends that some responsibilities probably should remain separate from case management — like risk management, for example. "Risk management is a specialty in and of itself," she says. "You have to have a good knowledge of the law and a good handle on national trends and legislation. The courses I’ve taken on nursing and the law make me wary about integrating that role."
For more information about the integration of case management departments, contact:
Elaine Cohen, EdD, RN, director of case management, co-director of the office of clinical practice and quality management, associate professor, University Hospital - University of Colorado Health Sciences Center, 4200 E. 9th Ave., Campus Box C300, Room 101, Denver, CO 80262. Telephone: (303) 372-7624.
Sue Erickson, RN, MPH, assistant hospital director, Vanderbilt University Hospital, 1161 21st Ave. S, Nashville, TN 37232. Telephone: (615) 322-7311.
Christine S. Sytsma, RN, MSN, CCRN, case manager, critical care, Winchester Medical Center, P.O. Box 3340, Winchester, VA 22604-2540. Telephone: (540) 722-8846.
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