Overcome the hurdles in cross-continuum projects
If your case management program is in the process of developing cross-continuum relationships with other community organizations, try including these tips to avoid potential implementation problems:
* Educate and gain sponsorship.
Case managers will need senior management and administrative support for cross-continuum efforts, notes Rebecca Trella, RN, MSN, director of care management at Advocate Health Care in Oak Brook, IL. Tell administrators what you plan to accomplish, and what results they can expect.
* Review data, and choose conditions to target.
For best results, pick a condition that constitutes a large number of patients that is complex, difficult to manage, and involves multiple sites across the continuum. The condition should involve high costs and financial loss across the continuum. The condition doesn't have to be a specific disease, Trella says. Advocate chose frail older adults because the patient group constituted a large percentage of the system's hospital census.
Another consideration: Start with conditions or diseases in which positive financial results and improved care between sites can be achieved.
* Evaluate necessary resources.
Decide which organizations within the community should be involved, and invite them to join. Don't forget organizations where patients receive services not associated with health care, such as day care organizations and social service agencies.
* Identify a team leader.
The entire project will need a leader to guide the steering committee and subcommittees. The leader can come from a hospital, home health agency, or other community organization.
* Begin literature search.
Find out what others in your area or across the nation have done in areas relating to your chosen condition. Include any benchmark data or reported outcomes as possible goals for your program.
* Form committees.
You'll need two types of committees: a steering committee and subcommittees, says Trella. The steering committee should be composed of physician leaders and administrators. The steering committee defines the goals, objectives, and format for the project.
Each care site should form a multidisciplinary subcommittee to develop a critical path for use within the site. A representative from the subcommittee also should report the group's progress to the steering committee.
* Assign a project facilitator on all committees.
Each subcommittee should include a project facilitator. This person will coordinate the implementation of the cross-continuum model within each specific care site. The project facilitator also works with the systemwide program managers to solve implementation problems and ensure staff involvement.
* Define current processes.
Each care site should review and flow-chart its current process of care. Review patient records and research from literature, and include patient input on current processes and areas for improvement. Physicians also should be included.
* Define appropriate process.
Develop a desired process of care for each site based on literature and consensus from experts. Each site should involve physicians in the pathway development process and create a pathway that can be used as a plan of care.
* Obtain committee review and approval.
Each subcommittee should provide the steering committee with an approved plan of care for its care site. Upon approval, the steering committee will incorporate the site's pathway into the overall project.
* Don't let subcommittees change the format.
Subcommittees should be encouraged to develop a critical path for each site to ensure continuity within the project and smoother patient transitions. Additional documentation or patient management tools can be adapted at each site, such as flowcharts, protocols, or mini-paths for other conditions that can be added to the existing pathway, Trella says.
* Create and use a standard language in pathway writing.
Each subcommittee should develop a pathway that is flexible for use on a majority of patients within the site, but also should make it user-friendly systemwide. Patients, for example, may be referred to as clients in a day care environment. Multidisciplinary and cross-site meetings can help providers determine an appropriate language.
* Make all participants responsible for sharing drafts with other sites.
Each subcommittee should inform all other care sites of its progress. Draft pathways, for example, provide other care sites with information on expected outcomes of patients being received from one site to another, Trella notes.
Advocate's Geriatric Care Network (GCN) was implemented in January 1995 and incorporates cross-continuum care management for frail elderly patients within the following care sites:
* acute care;
* inpatient rehabilitation;
* nursing home;
* home health;
* adult day care;
* physician office;
* outpatient rehabilitation.
GCN uses a care management approach rather than case management to help provide care for its members. "Care management is the implementation of a process to manage care for high-risk groups vs. an individualized approach to each client. As a result, patients can access services from any program in the network," Trella explains.
GCN, which is funded through a grant from Chicago-based Retirement Research Foundation, operates using a steering committee structure. Care sites then establish subcommittees to develop and define the best process of care for their respective sites.
The program is coordinated through two program managers who supervise each subcommittee's progress and educate each site on how to use the extended care paths. Program managers work with a dedicated staff member at each site, called a care coordinator, who is responsible for ensuring the paths are used. Program managers also courier patient information between care sites if necessary, Trella notes. *
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