Increase coordination, effectiveness of CM
Medical center saves money while boosting staff
By Alan Cudney, Associate
Premier Inc.
Charlotte, NC
Many hospitals today are struggling to coordinate the functional responsibilities of utilization review, case management, discharge planning, and social services. Because these services often are directed through different departments, the result can be internal conflicts, overlapping responsibilities, and a lack of communication preventing a hospital from achieving truly integrated, coordinated case management services.
Leaders at Alamance Regional Medical Center (ARMC) in Burlington, NC, were concerned that their case management activities were not as effective as they could be. Frequent insurance denials and late discharges were part of their concern. Consultants at Premier Inc. were asked to explore opportunities for improvement at ARMC in the areas of utilization review, discharge planning, social services, and clinical pathways. Two departments were responsible for the majority of those activities: patient and family services, and utilization review.
The utilization review department was staffed by three full-time UR nurses and two part-time nurses. Because of the low staffing level, these nurses often were limited to interacting with third-party payers to get certifications and manage denials. Most of their time was spent on the phone talking with insurance providers. The department was led by a director who also was responsible for clinical pathways. However, due to their time constraints, the UR nurses usually were not involved in the pathway activity.
The nurses in UR were aware that their roles as case managers were expanding. In their efforts to coordinate care for the patients, they began to perform discharge planning activities. However, a separate department at ARMC was responsible for discharge planning. That department, patient and family services, was staffed by three full-time social workers and one part-time social worker, plus an administrative specialist. This department was responsible for performing discharge planning and placement, as well as handling crises and adoptions.
Premier consultants performed a staffing analysis using Premier’s Case Management Staffing Model. (See related story in Hospital Case Management, August 1998, pp. 152-156, 161.) This mathematical model allows an organization to compare its staffing levels with hospitals of similar patient volumes and acuity levels to determine an appropriate range of staffing. ARMC’s staffing was at or below the low range of peer hospitals.
Premier also conducted interviews with staff and physicians. From this assessment, it became clear that interpersonal and professional conflicts prohibited the two departments from working together to coordinate their patient responses. For instance, each department claimed responsibility for discharge planning. Because of departmental rivalry, there was limited communication and coordination between the two groups.
In August 1998, Premier’s analysis led ARMC executives to merge the two departments under one director who could provide strong leadership. Working as one "care management" department, the staff could integrate work processes and capitalize on their existing resources. While the hospital recruited a permanent director, Premier provided an interim director to begin the merger process.
The interim director worked closely with the two previous department heads. These two staff members would remain in the new department, and together they brought more than 30 years combined experience. Their support for the changes was particularly valuable. A regular staff meeting was established in which all department members were encouraged to contribute their expertise to the change process. For the merged department to be successful, it was important to establish an environment of candor, trust, and collaboration.
Care teams ease merger
One of the first challenges was to create a process that would enable the two groups to work together effectively. Premier’s interim director, in collaboration with the two former department heads, created "care teams," which were implemented in December 1998. The care teams provide a successful model for integrating two complementary disciplines such as social services and utilization review.
As the flowchart illustrates (see p. 66), the care team assigned a nurse case manager and a social worker to work as a team for a specific group of nursing units, such as orthopedics and med/surg. Their complementary skills work well together and help achieve the integration of care that hospitals strive for. The nurse looks at the patient from a clinical progression of activities (what must occur during the stay to achieve the best outcome) and an insurance perspective (how we can be sure this is reimbursed correctly). The social worker has a strong knowledge of what services are available in the community, in addition to his or her knowledge of counseling and crisis intervention.
The Care Team model was structured to solve several problems. By beginning the assessment within 24 hours, the hospital was able to eliminate many delays. Previously, the family services staff had waited until the end of the patient’s stay to begin discharge planning. This often resulted in a longer length of stay. With the new program, the social worker is able to identify and prioritize the patient’s needs immediately and begin planning for those needs. The case manager is able to verify the patient’s status on the clinical pathway, verify insurance coverage and approved length of stay, and monitor the patient’s progress.
Communication is greatly improved with the implementation of an informal daily report, in which the team members discuss their activities and perspectives for each patient to ensure their efforts are coordinated. Team members also participate in a more formal discharge planning meeting held in each unit.
As noted earlier, the departments were understaffed as shown by the Premier staffing analysis. The merged department now was able to hire additional staff to achieve a staffing level that came closer to the benchmark of peer hospitals. This resulted in the creation of three care teams, plus the addition of weekend coverage and specialized staff assignments, such as one social worker dedicated to skilled nursing placements and the previous department head assigned housewide for the most difficult cases.
The results will be measured through a set of indicators currently being developed. Among other data, the hospital will collect information on:
• proportion of patients with excess lengths of stay;
• percentage of patients managed on clinical pathways;
• insurance denials;
• overall patient satisfaction.
Implementation of care teams at ARMC still is evolving, but this concept has provided a useful structure for merging two departments involved in coordination and planning of care. Working together in teams already has led to a noticeable increase in coordination between the two disciplines. In addition, relationships with physicians and floor nurses have been greatly improved as the team members work in conjunction with the unit’s staff on a daily basis. Hospital executives believe their organization is closer to the goal of effective case management, resulting in integrated, coordinated care and improved patient outcomes.
Alan Cudney is an associate with Premier Inc. in Charlotte, NC. He can be reached at (704) 679-5098.
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