Hospital system scales back its integration efforts
Emphasizing utilization management, not review
When it comes to integrating case management functions, Fresno (CA) Community Hospital was an early adapter, bringing together utilization management, discharge planning, infection control, and quality assurance as early as 1991. It soon became apparent, though, that in trying to coordinate all these responsibilities, the case management department had bitten off too much, and was soon forced to scale back its integration efforts.
"We went through a major redesign [in 1991]," says Karen Gattie, RNC, BSN, a master path case manager at Fresno. At that time, the hospital contracted with an outside consulting firm, which came to the conclusion that total integration was the best way to go, together with representatives from case management and hospital administration. "So it was designed by outside consultants and then developed by us internally," Gattie says.
Two years ago, recognizing that case managers were being pulled in too many directions at once, the hospital ended the experiment, once again separating out social services and infection control. "Infection control exists again because there wasn’t enough time to be devoted to the management of the extreme infection control problems," says Miriam Sommers, RN, BSN, service coordinator at the hospital. "We certainly could do screenings, but to carry out the work that needed to be completed with infection control required the infection control department to come back. It fragmented us too much."
The department made other adjustments away from the initial plan as well. For example, it was originally decided that nurses and social workers in the department would both be considered case managers. "As time went on, we decided that RNs are the case managers and social workers would be consultants, except for in psych and rehab," Gattie says. In addition, rather than assigning case managers by payer source an approach that had them "running all over the hospital," Gattie says case managers were assigned to units "because of specialty, the nurses’ ability to know staff and put the whole piece together in a better way."
Utilization management and discharge planning, however, remain important aspects of the case management department, Sommers says. "Our philosophy is that, as you’re doing the utilization, you can anticipate the needs patients might have, or you can see things that have changed in their lives due to their condition and help to anticipate some of the needs they may have as they progress through the healing process."
Because many case managers at the hospital already had some experience with utilization, formally bringing utilization on board didn’t require a huge adjustment, adds Cindy Perkins, RN, a case manager at Fresno Community who had worked in utilization review (UR). "There was a core of people here who brought with them the feeling that now, in this health care era, you have to combine some clinical knowledge and some financial knowledge in order for our corporation to survive, and in order to give the best care and get the best outcomes for the patient," she says. "And we had people coming in who wanted to keep that balance of financial and quality care for patients."
Gattie stresses that what case managers at Fresno Community do is utilization management, rather than simply UR. "UR implies a retrospective process, and case management does not lend itself very well to that," she contends. "Case management is more proactive, more current. To me, utilization management means that we’re looking at this now, we’re doing something about it now. We’re not going to identify it and then tell everyone what they should have done."
Sommers says the hospital’s case managers have worked hard to establish relationships with physicians, to the point where physicians now actually seek out case managers for advice on utilization matters.
"We’re not the utilization police," Gattie says. "That’s what we were before, in UR. Basically, you parked in the wrong place, we gave you a ticket, and everybody was upset. Now, we’re more like the traffic director who stands in the middle of the street saying please don’t park there; turn left here.’ We’re working together to do the right thing. But it took a while to get there."
For more information about case management at Fresno Community Hospital, contact the following:
Miriam Sommers, RN, BSN, service coordinator; Cindy Perkins, RN, case manager; Karen Gattie, RNC, BSN, master path case manager, Fresno Community Hospital, P.O. Box 1232, Fresno, CA 93710. Telephone: (209) 442-6000.
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