Hospital brings social work into case management fold
Disciplines keep distinct focuses in one department
When 240-bed Jefferson Memorial Hospital in Crystal City, MO, decided to integrate utilization review and social work into a single case management department in 1994, administrators knew they were in for a challenge. But it was clear something had to give. Managed care was just beginning to hit the local health care market, and the hospital already was struggling to keep down its lengths of stay for Medicare patients.
"We had good-quality care, but it was too expensive and took too long," says Chris Johansen, RN, manager of case management services at Jefferson. Recognizing this, the hospital’s chief financial officer made the decision to restructure the social work department and combine it with utilization review under a single department head.
Resistance from the social workers came immediately. "There were some people in social work who were not interested in that type of department structure and didn’t want to be involved," Johansen says. Their main concern was that the focus on shorter lengths of stay would necessarily limit the amount of time they had to build relationships with patients.
The new combined system features seven case coordinators and three full-time social workers. The case coordinators perform screening for social work and home health and then refer cases to a social worker if necessary. Because of the department’s structure, it’s not unusual to have both a case coordinator and a social worker working on the same case at the same time.
One benefit of the combined system has been the elimination of duplicate telephone calls to insurance companies regarding patient benefits, Johansen says. "It seemed silly to have a case manager trying to get the hospitalization covered and then have a discharge planner come in right after her, look at the chart again, call the insurance company again, and have to do the whole thing over again to get the home care set up," she says. "By combining those responsibilities, we’ve become much more efficient."
Johansen notes that although they work in the same department, case coordinators and social workers still maintain some separation of responsibilities. "A nurse doesn’t ever want to be a social worker and a social worker doesn’t ever want to be a nurse," she says. "But sometimes you have a fuzzy area regarding who would be the most appropriate to help take care of a particular case." For such cases, the social worker and case coordinator are given the latitude to work out what their individual responsibilities will be.
"Nurses are very comfortable with complex medical issues, but when it comes to family dynamics, relationships, adjustment problems, and complicated community referrals, they’ll usually call a social worker, because that’s just something they’re not trained for," Johansen says.
When they began the integration process, they started with a single case coordinator and built a job description from scratch that expanded greatly on the job description used by the old utilization review department. (See draft of Jefferson’s new job description for case coordinators, p. 34.) Based on the new job description, Johansen hired four more case coordinators. All came from in-house and were therefore already familiar with the facility and its physicians. And all had considerable experience in nursing.
New social workers also were brought in. "They were mostly younger ones who hadn’t had a lot of prior experience," Johansen explains. "It seemed that the people with a lot of experience were used to a different way of functioning. It was a barrier for them, and they weren’t comfortable with [our system]." Another barrier was that the combined department was headed by Johansen — a registered nurse — a fact that put off some social workers.
"When we hired people, we just laid it out to them," Johansen says. "Because the new department was built from scratch, we didn’t have a lot of people left over from the previous departments. I told the new people right up front, This is the way we’re going to function. It’s a dynamic department, it’s multidisciplinary, and it’s very busy. If you don’t mind high-intensity, fast-paced work, then this is the place for you.’"
To train the new hires, Johansen developed an intensive six-week orientation program. The curriculum was divided into several categories, including review and referral to home care, nursing homes, and hospice. During this process, the trainees visited the hospital’s affiliated home care company and performed some home visits. They also made nursing home visits and toured a rehabilitation hospital in St. Louis. At each location, they were required to fill out a questionnaire to test what they had learned. "It gave them an opportunity to touch base with people, see the facilities, and get answers to some of their technical questions about referring," Johansen says.
The trainees also visited colleagues in the case management department at Barnes Jewish Hospital in St. Louis. "They were a little bit ahead of us in their case management program, and they allowed some of us to come up and round with them and see how they functioned. That was very beneficial," she says.
In addition, Johansen saw that the new hires were trained on reimbursement structures, Medicare and Medicaid, what private payers offer, and how to access it.
Now that the program is established and the case coordinators are more comfortable in their new roles, training has become easier, Johansen says. "Now, we have people that we can buddy [new hires] up with. It took a while to build this, and in the beginning, I would end up doing a lot of the training myself, because there just wasn’t anything out there," she says.
For more information, contact Chris Johansen, RN, manager of case management services, Jefferson Memorial Hospital, P.O. Box 350, Crystal City, MO 63019-0350. Telephone: (314) 933-1226.
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