Discharge Planning Advisor-New tool places resources where they're most needed
Puts patients in risk category to match services
Not every patient needs 100% of the available services in a hospital.
In a nutshell, that's the premise behind a new risk stratification tool developed by the Center for Case Management (CCM) in South Natick, MA.
Dedicating valuable and expensive services to patients with low risk is not an efficient use of a hospital's resources, contends Shawna Kates, ACSW, LSW, CMAC, who designed the risk stratification tool in collaboration with Karen Zander, principal and co-owner of CCM.
The tool is an outgrowth of the contemporary case management theory espoused by CCM, in which "we're not diluting the profession by cross-training, but rather re-emphasizing the contribution made by diverse team members, explains Kates, an associate with CCM based in Cherry Hill, NJ. "Utilization is distinctly different from clinical nurse management, which is distinctly different from clinical social work, and all three are beneficial to patients."
Health care has moved from the old-fashioned, lengthy hospital stays in which every patient got every service despite the cost, "to the contemporary posture in which we differentiate among our professionals," she points out. "The goal is to use them to best advantage." At the same time, there is the growing emphasis on continuity of care — "not just care for those admitted to the hospital, but primary care and ambulatory care."
With that in mind, risk stratification, says Kates, "is a combination of assessment and planning, in terms of identifying what the patient's strengths and weaknesses are and matching those with the services the hospital can provide." Placing patients in categories of risk, she adds, determines the level and content of the service to be provided.
The risk stratification tool, Kates explains, is an operations piece for health care, as well as an outcomes piece for patients — "a look at redeploying our experts." Placed in the lower category of risk, for example, would be a patient who needs less clinical intervention, has more social resources available, and is able to cope intellectually and emotionally, she says. "If a person is low on the risk stratification scale, the plan would include following up with the physician, confirming the patient's self-education, and then discharging the patient."
A patient at the high level of risk, on the other hand, would be a person with multiple hospital admissions, who is already receiving home services, with few resources for coping emotionally or financially, Kates adds. "[Those factors are] a red flag that this person will utilize, and should have dedicated to him or her, maximum services, and may require nursing and social work case management."
For that patient who is high on the risk scale, there might be a consult with a pain physician, a psychiatric evaluation, and a referral to rehab or long-term care, she says. "With every assessment, there is a plan that includes which caregivers are needed. It is all data-driven, so we can track back and say, 'Did we identify this issue; did we follow through?'"
This contrasts with traditional case management, Kates points out, "where every patient is evaluated for everything. Even though [the patient] is alert, oriented, with good family support, lots of time is spent discussing, writing, and re-evaluating. That time could be spent on a patient with higher risk."
The key to effective use of the risk stratification tool, she points out, is not only what the patient needs when he or she leaves, but rounding up the most effective team to make those care decisions. Ask the question, Kates suggests, "Who is the best expert to identify the services the patient needs?"
"It's that whole concept of collaboration," she says. "A clinical nurse resource person is captain of the team. But depending on what the risk is — clinical or social or medical noncompliance or pharmaceutical — there may be an 'expert subcaptain.' Sometimes it might be a physical therapist, because that is what's most needed. If there is a lack of social resources, then social work needs to rise to the fore."
Given the shorter lengths of stay in today's hospital environment, Kates points out, time is of the essence. "The team needs to begin teaching [the patient] early on, identify the resources needed, and do this with mindfulness of the cost of it all. "When I started out in the business 30 years ago, there was a three-week relationship with the patient in which to hone skills and build trust between the family, the patient, and the team," she notes. "Now you have to take all those skills and wrap them up in a ball and offer them to the patient in a very brief period of time. This requires greater sensitivity than ever before, and the health care system has to have unique access to services."
With the effectiveness of critical pathways, this directing of the patient to the appropriate team member sometimes happens almost inherently, Kates says. "When a patient comes in with a certain medical diagnosis, the case manager may say to the social worker, 'This patient will really fall into your bailiwick.' But, if the system is structured so that it's 100% case management, it's still not as efficient."
CCM's term for what needs to be done is "funneling," she explains. "They all are your patients, but down the funnel you look at weeding some out, and are left with those with the greatest need who will consume the greatest services. That's where your effort needs to be." (See related story, at right.)
Part of the philosophy behind the risk stratification tool, Kates notes, is an outgrowth of the "new case management," which in fact has its roots in the first part of the 20th century. "The social work side traces back to the early 1900s at Massachusetts General, where Dr. Richard Cabot founded the first social work department."
Social workers' jobs then were to work closely with the original public health nurses, following people who had been treated in the infirmary into the community, she adds. It's this kind of collaboration that makes for successful case management, Kates says. "The idea of 10 years ago — the diluting of the two professions by cross-training everybody — is not efficient. Patients should have the diverse services," she adds. "A pharmaceutical case manager is different from a nurse case manager, so allow patients to receive the services they need most. It's also cost-efficient and quality-wise."
A nurse case manager and a social worker approach the same situation in two different ways, Kates explains. "When doing an assessment, a nurse case manager is looking at physicality, medication management, skin, wounds, pain. The social worker looks at, 'Was the patient taking medication at home? Is the patient already using durable medical equipment at home? Does the patient have financial resources?'"
The risk stratification tool, she says, deploys the best experts to patients in a kind of triage process. "It allows us to identify what the patient needs most, and have that service delivered by the most capable person in the most efficient process to achieve the very best outcome."
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