Implementation and coordination of daily case management process in action
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
[Editor's note: Last month in Case Management Insider, we started our discussion on the case management process. We reviewed the first two steps in the process which were "selection and screening" and "patient assessment and diagnosis." In this month's edition we will continue to review the steps that case manager's use in their daily work to achieve positive outcomes for their patients and their organizations.]
Like any process used by a healthcare professional, the steps of the case management process are not always linear. At times, they might zig zag and alter course. However, there are steps to be completed, even if they are not always in perfect sequence.
In last month's step two, "patient assessment and diagnosis," we looked at a sample case management assessment form. This form should be completed on the day of admission to the hospital so that the next steps in the process can be completed. The information collected in Step 2 helps the case manager understand exactly what the potential discharge destination will be and sets the course for the hospital stay as well.
Once the patient has been identified and the initial assessment has been completed, the case manager must begin step 3, which is to create a case management plan of care.
The plan should be based on the needs identified during the assessment process. The assessment includes a review of the current and prior medical records, including the emergency department record if available. It also includes an interview of the patient and family, or family caregiver. Finally, the case manager should speak with the attending physician of record to gather as much relevant information as possible, including what event precipitated admission to the hospital.
In collaboration with the healthcare team, the case manager develops an interdisciplinary plan of care that includes expected outcomes of care, day-to-day interventions, an interdisciplinary teaching plan, and a discharge plan. The case manager may use a pre-existing national guideline or a hospital-specific guideline as the foundation for the plan of care. In some instances, multiple diagnoses might be involved, and an integration of more than one plan might be necessary. The plan should allow for the most cost-effective interventions possible, while optimizing each day that the patient is in the hospital. In addition, the plan must be developed with the patient, family, and/or family caregiver in mind as well. Once the plan is developed, it should be discussed with the entire interdisciplinary care team and modified if necessary. Consideration should be taken to include all members and the interdisciplinary outcomes of care.
Finally, the plan should be discussed with the patient and family so that the care progression and length of stay are clear to them and leave no room for surprise. This time is the case manager's opportunity to review the anticipated discharge destination as well. The clinical needs of the patient must be coordinated and facilitated with the interdisciplinary care team and the ancillary departments. This step will help to ensure that care is progressing appropriately. Each day must be optimized so that the patient meets an acute level of care. This optimization ensures an appropriate stay as well as appropriate level of reimbursement.
A plan also must be created to address any psychosocial and/or financial issues that might have been identified. The plan may include a referral to social work, psychiatry, clergy, or palliative care, among others. It also might include a referral to a financial counselor or other appropriate person if a Medicaid application is needed. Other financial needs might include financial assistance in obtaining medications or other needed resources. Depending on the resources available in your hospital, you might be able to obtain some, or all, of the needed resources internally.
Step 4: Link patients to needed services
In terms of the daily case management process, once a patient's case management plan has been developed and reviewed with the interdisciplinary care team, a case manager can begin step 4: Reach out to the other departments or disciplines with whom the patient might need to be interfaced. This step also is known as coordination and facilitation of care.
For example, the patient might need to be referred to the social work department. Depending on the role of the social worker in a particular hospital, this referral might be for nursing home placement, psychosocial counseling, or crisis intervention. The sooner the assessment is performed after admission, the sooner the referral process can take place.
The same logic would apply to a referral for home care services. Making the home care referral as soon as possible after admission will reduce the potential for a delay in obtaining those needing home care services that ultimately can mean an increase in the length of stay.
Case managers play an important role in ensuring that care is received as appropriate and in a timely manner. This happens through proactive coordination of the processes and then the actual facilitation of those processes. For example, if a patient needs to have an MRI to make a definitive diagnosis, and there has been a delay in getting that MRI done, the case manager would be responsible for determining the cause of the delay and correcting it. This component of the case manager's role impacts quality of care, cost, and length of stay. To perform this step well, the case manager must have worked with the team on the development of the plan of care and goals of care.
If the patient needs a referral for financial assistance, this step also should be done as soon as possible. If it is anticipated that continuing care services are going to be needed in the community, the sooner a Medicaid application is initiated, the less delay there will be as the patient progresses toward discharge.
Other types of referrals might include pain management or palliative care. Palliative care should always be a consideration for case managers when the patient has a chronic condition, issues with pain management, or is at end of life.
In some circumstances the case manager might identify a needed consult or referral, but he or she might need to obtain a doctor's order for the consult or referral. If this process is the one used in your hospital, then you should speak to the attending of record, provide your rationale for the consultant or referral, and ask that it be ordered. In other instances, you might not need to obtain a doctor's order, but you might be able to facilitate the process independently.
Step 5: Implement, coordinate patient needs
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
The case manager must ensure that the patient's clinical needs are coordinated and facilitated throughout the hospital stay with preparation for the post-acute setting as well.
This step 5 in the daily case management process is dependent on the development of an interdisciplinary plan of care with achievable care goals for each hospital day. Among the interventions that might require coordination and/or facilitation are included tests, treatments, procedures, consults, and education. In step 5, we listed some of the types of consults or referrals a case manager always should be thinking about.
In addition, the case manager must ensure that diagnostic interventions and treatment interventions are occurring in a timely and appropriate order. The case manager plays a critical role in determining the full set of interventions necessary and then choreographing them so that there is no out-of-sequencing and no delays. It is during this process that the case manager would be evaluating for redundant or duplicate ordering that might drive up the cost of care without adding any quality to the process. This problem is not uncommon in radiology testing and laboratory testing. Not only do redundant tests increase cost, but they also increase the length of stay and expose the patient to interventions that they might not need.
Any clear delays should be logged in as avoidable delays and should be corrected at the point of care whenever possible. Look at these delays in real time but also in the aggregate so that patterns and trends can be corrected over time.
The plan of care should be shared with the patient and family so that they understand the potential services that the patient may receive while in the hospital and following discharge to the community. Case managers should clearly identify their role to the patient and family, as well as the expected outcomes of care for the hospitalization. Engaging the patient, family, or family caregiver is an important component of the coordination-of-care process. The more information you provide to the patient and family, the greater the likelihood that they will be able to participate in the care processes and discharge planning processes.
This step is also an important way to improve patient satisfaction. One of the bigger patient complaint areas is lack of communication. Remember that the patient and family might need to hear information more than one time due to pain, anxiety, sedation, etc. By communicating with the patient and family from the beginning of the hospital stay and daily throughout the stay, the case manager can reduce the likelihood of missed or misunderstood information.
Implementation of the plan of care requires good verbal as well as written communication. Verbal exchanges can take place on interdisciplinary care rounds and informally throughout the day as needed. Communication should include both the giving as well as receiving of information. In addition, information can be shared in the medical record as another means of communication, and as legal documentation of the plan of care and appropriate interventions.
The sequencing of patient care processes falls under the role of patient flow and is one of the most important functions that a case manager performs. By coordinating care, the case manager ensures several items. These include:
- proper use of resources including reduction of duplication or redundancy;
- management of the length of stay;
- decreased likelihood of receiving a denial;
- improved patient satisfaction.
Step 6: Monitoring of care processes
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
As with the other process steps in the daily case management process, monitoring is a step that goes on continuously and repeatedly.
Monitoring, which is step 6, involves the continuous overseeing of the patient's movement toward, and/or achievement of the goals of care. You might need to adjust the plan as the patient's condition progresses toward discharge. The case manager must assess and reassess the patient on a daily basis to determine progress and whether changes to the plan are needed.
Assessment takes place using a variety of strategies. Included are daily patient care rounds. Rounding is a great way to engage with the other members of the interdisciplinary care team and work together to determine the patient's progress toward the achievement of the goals of care.
It is also during rounds that a discussion can take place if a change in the plan is needed. By actively discussing the goals of care, the team can keep an eye on the expected length of stay and adjust it as needed. This step might mean shortening the expected length of stay if the patient is progressing more quickly than anticipated, or lengthening it if the patient is progressing more slowly.
Other assessment tools include a daily review of the medical record, particularly looking at lab and radiology results, and nursing and physician documentation. Ongoing monitoring is helpful in length of stay management, but this information also can be used to inform the clinical review provided to the third party payer, if necessary. This information is also critical to the determination of the transitional and discharge plans. While some case managers might think that they cannot provide the time needed for ongoing assessments, clearly this information ultimately can streamline many of the other roles and functions that the case manager must perform.
Final steps: Advocacy, evaluation and follow-up
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
Advocacy is more than a step in the case management process. As discussed in a prior issue of Case Management Insider, this element is applied to all the roles and functions that a case manager performs. Therefore the case managers should be thinking about their role as patient advocate at all times.
Advocacy occurs on many levels. The case manager might need to ensure that tests, treatments, and procedures are occurring in a timely fashion (patient flow). The case manager might need to advocate for a continued hospital stay with a third party payer due to the patient's speed of care progression (utilization/denial management). The case manager might need to advocate for continuing care services in the community (discharge planning). The case manager might have to advocate for a specific consultation, such as palliative care, for example.
Dilemmas can arise when the case manager has to advocate for interventions that might increase the length of stay or the cost of care. Whenever these kinds of issues arise, the case manager always should place the patient in the forefront of the solution and consider cost secondary.
The case manager's role as a patient advocate cannot be overestimated. It is a critical component of the work of the case management and of the case management process. Each time a case manager makes a decision on behalf of a patient or family member, their role as patient advocate should be foremost in their mind.
Evaluation and follow-up
The case manager must continuously evaluate the patient's progress toward expected outcomes. Evaluation is based on the assessment done as described in step six. Evaluation, which is step 8, involves the critical analysis of the information collected during the assessment and reassessment processes. It requires that a decision be made as to the next steps and/or change in the plan of care.
Evaluation cannot be done in isolation, but rather it should be done collectively with the entire interdisciplinary care team. Eventually the patient will transition to the next level of care. The case manager has a responsibility to ensure that the progression is timely and appropriate. If the patient is discharged to home, the case manager should follow up to ensure that the planned services are received and that the patient's needs are being met.
Many case management departments have begun calling patients after discharge to evaluate whether continuing care services have been activated in the community. This follow-up call can be done by one of the professional staff members or a clerical staff member. If clerical staff members are used, they should have a carefully worded script to use and should have clear criteria as to when to escalate an issue if necessary. Calling patients can be labor intensive; sharing the work between clerical and professional staff can be one way to address this problem.
Consider post discharge follow-up in the context of readmission reduction, coordination of care across the continuum, patient satisfaction, and reduction of inappropriate emergency department visits and/or admissions.
In this issue we have discussed the importance of using the case management process as a structure for organizing the work of case managers in their daily practice. While the process is not linear, it does provide a context with which to organize work that can sometimes be variable and unpredictable. In the day-to-day life of a hospital case manager, the work will vary according to the needs of the patient on a given day and at a given moment. Because of this challenge, having a structured framework can be a valuable tool, as the case manager works toward achieving specific outcomes on behalf of the patient, the family, and the organization they work for.
[Editor's note: Last month in Case Management Insider, we started our discussion on the case management process. We reviewed the first two steps in the process which were "selection and screening" and "patient assessment and diagnosis." In this month's edition we will continue to review the steps that case manager's use in their daily work to achieve positive outcomes for their patients and their organizations.]You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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