CMs, social workers thrive under triad model
Responsibilities are negotiated by team members
As early as 1993, administrators at 600-bed Vanderbilt University Hospital in Nashville, TN, conceptualized a new kind of case management program based on the assumption that case management is not a role but a process of guiding patients through a continuum of care.
They further refined that idea by calling for an interdisciplinary collaborative process that would include the contributions of three main disciplines: case management, social work, and utilization review (UR).
The motivation behind Vanderbilt’s new approach was the recognition that the hospital’s case-mix index was far too low for its patient population. "When we went in and did an analysis, we found that it wasn’t a coding problem; it was a documentation problem," says Sue Erickson, RN, MPH, assistant hospital director. "If the documentation’s not there, coders can’t reflect and say, Well, it’s clear the patient’s in failure, even though somebody didn’t write those words.’"
Even in 1993, administrators saw that the hospital’s social workers and case managers were working together fairly well. The problem was the utilization review department, which operated in the basement of the facility. "We had a very old-fashioned UR program that was perfectly poised to be successful in 1970," Erickson says. "They were not credentialed or licensed staff, and they did not connect to the clinical practice at all."
To fix the problem, Erickson and her colleagues transformed UR into a utilization management (UM)/diagnosis-related group (DRG) management model. In doing that, they also tightened job requirements so that everyone on staff had to be licensed or credentialed as an RN, LPN, RRT, or ART. And all staff underwent what Erickson calls "a massive training program: They learned to do not only traditional review processes but also concurrent review of the chart and actively managing the DRGs, to make sure that the documentation supported and reflected the severity of the patients we were managing."
Originally, it was decided that the UM/DRG staff also would do some actual coding in addition to concurrent review. But that idea was dropped early on, Erickson says. "Coding is like being a tax accountant," she says. "All of us can fill out our tax forms, but if you have a complicated tax profile, you probably want somebody who really knows the esoteric little rules to fill out the final forms. With coding, you want someone who understands all the nuances of the regulations to do that work."
Because of the tough new requirements, only a few members of the existing UR group chose to stay on. Those who did, and the new staff who were hired, were assigned to work with case managers and social workers in teams Vanderbilt calls "triads." (See triad chart, p. 4.)
In the triad model, every population of patients is assigned a case manager, a social worker, and a UM/DRG specialist. The social worker and UM/DRG specialist, however, may work as part of more than one team. In addition to working in triads, the UM/DRG staff are located on the floor of the unit with which they work, rather than in the basement, where they were previously.
Although triad members share some responsibilities, such as screening and discharge planning (which can be done either by the case manager or social worker), each team member retains a separate and distinct focus. "We strongly believed that nurse case managers should focus on the medical needs of the patients and be a resource to the utilization management people when it comes to insurance issues," Erickson says. "What we’ve tried not to do is build a model where our nurse case managers spend a lot of time on the phone interfacing with payers. That’s really the role of the UM/DRG specialist."
The line separating the responsibilities of social workers and case managers, however, is less distinct. Erickson acknowledges that some overlap does occur. "We believe that the social worker and the nurse case manager can both do assessment of risk and discharge planning, yet each team has to learn where to draw the boundaries," she says. "When issues are dominantly psychosocial, they would be handed off to the social worker, whereas the nurse case manager would be more likely to handle medically driven issues. There’s some negotiating about who handles what patients, but they’ve worked it out to a fairly fine science."
Erickson adds that one indication of the level of cooperation between social workers and case managers is the fact that her new director of case management is a social worker who also directs the department of social work. "So now we have a social worker who’s really administering the entire endeavor," Erickson says. "She will not be responsible for professional nursing practice, but she is responsible for the practice of case management."
For more information on Vanderbilt’s triad model for case management, contact:
Sue Erickson, RN, MPH, assistant hospital director, Vanderbilt University Hospital, 1161 21st Ave. S, Nashville, TN 37232. Telephone: (615) 322-7311.
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