CM, social work duties handled by specialists
Specialists assist with post-acute placement
At St. Vincent’s Medical Center in Jacksonville, FL, three different staff positions handle duties that traditionally have been performed by case managers and social workers.
Two staff assistants handle referrals for home health services, durable medical equipment, ambulance, and transportation services. The staff assistants are notified by the clinical staff when referrals need to be made. They make the referral electronically and get the response back either electronically or by telephone. Then they notify the clinical staff of the acceptances or rejections.
The staff assistants handle the paperwork involved with patient transfers to nursing homes, rehabilitation facilities, long-term acute care, and outpatient dialysis units. They assemble the packet of information that goes with the patient. Both staff assistants have held that position for more than four years. They have high school diplomas and have received training within the department.
The staff assistants are assigned by unit so they work with the same care managers and social workers. They communicate with the clinical staff through beepers and text messages.
A placement specialist works with the social workers on post-acute placement. The social workers notify her when a patient needs placements and give her direction as to which nursing home, rehabilitation facility, and outpatient dialysis center the patient or family member has chosen.
The placement specialist goes into the clinical system, pulls out clinical data, demographics, and other pertinent information and sends it electronically to the facilities receiving the referrals.
"She has no patient contact. The social worker notifies her that a specific patient in a certain room needs to be referred to whatever facility the patient and family have decided upon, and she takes it from there," says Jamie Zachary, LCSW, director of care management.
The person originally hired for the position had a bachelor’s degree in social work but Zachary determined that a degree is not necessary; when the original employee left, she replaced her with someone with a high school diploma.
"The job obviously requires computer skills. If the social worker had to communicate all the referral information, it would defeat the purpose. The placement specialist can go into the clinical system and pull out all the information she needs for the referral without having to look it up in the chart," she says.
Three payer specialists are each assigned a group of care managers to work with in facilitating the flow of clinical information between the hospital and the payers. If a payer calls and requests clinical information, the payer specialist sends the request to the care manager electronically, and it comes up on the task list.
Working with payers
After the care manager conducts the review, the information goes to the payer specialist, who gets the clinical review to the payer, whether electronically, by fax, or by telephone, depending on what the payer has specified.
"There are some payers who don’t call in requesting reviews, but we know that this payer wants a review at some interval. The payer specialists identify those and task them to the care manager," Zachary says.
If an insurance company needs clinicals to complete authorization or precertification, the admissions clerk sends the information to the payer specialists and they notify the appropriate care manager.
"The only time the care managers have any contact with payers is when a payer sends a nurse reviewer on site, and then only if there is a question or a problem. The on-site reviewers check in with the payer specialists and go over the list of the insurer’s patients in house. When the on-site reviewers notice an issue related to clinical care, they bring it to the attention of the care manager.
"Care managers don’t call the insurance companies for anything. If authorization is needed for home health or DME, the staff assistants handle it. The placement specialist obtains authorization for placement. If the insurer needs more clinical information, they talk to the payer specialists," Zachary says.
The clerical support staff were added to the hospital’s case management model when it was revised in 2002. At that time, the department had one staff assistant who copied charts, ran faxed prescriptions to the pharmacy, and assembled clothing or food for patients who needed it.
Prior to the department redesign, care managers did only chart review with no patient contact.
"Now that we have added clerical support, the care managers have the time to see the patient on their unit, complete a needs assessment, and refer for ancillary personnel as indicated," Zachary says.
Social workers handle all placements and the complex home health needs, such as wound vacs and IV antibiotics.
"We try to keep the care managers focused on care coordination, with the end result being that the patient moves to the next level of care in a timely manner," Zachary says.
At St. Vincents Medical Center in Jacksonville, FL, three different staff positions handle duties that traditionally have been performed by case managers and social workers.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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