By Melinda Young
Placing case managers in acute care and ambulatory settings to focus on transitions of complex patients could help shorten length of stay (LOS).
“We have had month-over-month improvement in the percentage points of our length of stay efficiency domain, which means we’ve had a decrease in length of stay from November 2022 to September 2023,” says Angela Carter, RN, BSN, MHA, ACM-RN, senior director of system case management at Novant Health in Winston-Salem, NC. Carter is scheduled to speak about managing complex patients at the National Conference of the American Case Management Association in April.
The complex case management program includes a Complex Patient Placement Case Review Team, which meets on Fridays at 2:30 p.m. Team members bring complex cases with placement challenges to the meetings.
“Our Friday complex patient placement forum brings together a variety of expert leaders from across the system to hear stories of patients with challenging discharge barriers,” Carter explains. “After hearing the case, everyone has an opportunity to share best practice strategies that have worked on previous patients in similar situations or bring to the table a new idea we might try.”
Those presenting cases at the meeting receive recommendations and next steps. Senior leaders attending the meeting benefit from learning about the challenges and barriers that case management team members work on daily. “The meeting is just one way that case management can feel supported knowing that everyone is accountable for problem-solving these cases together,” Carter says.
When the complex patient program began, they were reviewing more than a dozen cases of 100-day-plus LOS per week. Now, they review 35-day LOS cases in the same amount of time because there are fewer 100-plus LOS cases to put on the review roster, according to internal data.
“We’re definitely [transitioning] patients more quickly and learning how to manage the cases much earlier in the stay — before they get to greater than 35 days LOS,” Carter says. “I’m very proud of the work that case managers and leaders are doing with these complicated situations.”
Achieving those results requires a strong commitment to case management and care coordination through staff training, policies, and resources. “One of the things we’ve done this year consistently is to train case managers to update the statewide document for Medicare/Medicaid certified facilities, called FL2 forms,” Carter says. “Those describe patients’ medical condition and the amount of care they’ll need in a facility.”
Case managers send FL2 forms — which are used to designate that Medicaid will only pay for skilled nursing care — to facilities throughout North Carolina. Sometimes, the forms are sent out of state when there are no local bed offers.
“We have very limited facilities in our area, and so we often have to send these out to bordering states for special types of beds, like ventilator facilities,” Carter explains. “We also make phone calls, daily, to skilled nursing facilities that we know take certain types of patients to see if they have any beds available.”
Case Managers Need Support
A discharge facilitator, who is an administrative team member who supports case management, is assigned this role.
“This keeps case managers at the top of their role, including meeting with patients and continuing to have weekly patient and family care conferences,” Carter says. “It’s a waste of time for a case manager to call a facility daily when it doesn’t have any beds.”
But if the discharge facilitator finds that a facility has a bed, then the case manager could review that transition. “It’s partnering an administrative team member with a case manager to make phone calls,” Carter says.
The case management support staff making those calls have other tasks, including scheduling ambulances, calling home health companies, and completing administrative paperwork to support case managers. “We have two resource centers that have full-time [case management support] team members in each,” she says. “Each resource center supports about five to six acute care facilities.”
Every acute care facility employs complex case managers, typically including one registered nurse and one social worker. They work as a pair and have their own caseload, Carter says. Leaders help determine which cases qualify as complex cases.
“We developed an escalation pathway for team members to know what to escalate and when to escalate [a case to complex case management],” she explains. “The goal is to identify early.”
Solutions for Tough Cases
The Complex Patient Placement Case Review Team is comprised of leaders in the areas of case management, nursing, legal, compliance, risk management, patient partnership, ethics, behavioral health, post-acute care, and clinical affairs. “The directors of case management, the vice president of case management, and I attend. We also include the case manager in the meeting,” Carter says.
The case manager presents the case, sometimes with the case management director. Typically, there are two to three cases every Friday. “The director would decide whether this is a true difficult placement or whether we just need to support them at a different level,” Carter says.
Team meetings are for cases that case management leaders cannot resolve. “We have crossed every bridge we can and have come to a dead end and need some more [advice],” Carter adds.
Dead-end cases could include patients who lack capacity and do not have family members or caregivers who will help make decisions. “Guardianship might be the next step for them,” Carter says.
Other problematic cases may involve a patient who is not a citizen and needs a high level of post-acute care. This could involve helping the person return to their home country, but that is a costly option.
“Sometimes, we have patients and families who may need more help with understanding goals of care, and maybe not everyone in their family is aligned,” Carter says. These patients could have a complicated medical situation or legal issue that is unresolved.
Having a room full of experts in various areas can help find solutions beyond what case management can do on its own. “We make suggestions for the next steps for the case, so we’re all aware of how we’re supporting both the case manager and case management leader,” Carter explains. “It’s a high level of upper leadership, and we listen to the case in a SBAR-Q [Situation, Background, Assessment, Recommendations, and Questions] format.”
The team makes recommendations for follow-up and the next steps. “That has really helped us as a system to get better with managing these complex patients,” Carter says. “Everyone understands at every level what the barriers are to discharge, which has been helpful.”
The meetings are popular and well-attended, Carter notes. “All of these disciplines are key, and they’re interested in helping to find solutions to our case management barriers,” she says.
Policy Changes
With a large health system and multiple acute care facilities, experiences are shared by all. They learn from each other. Having a team with a wide variety of disciplines also is instructive. “We have partnerships with legal, providing recommendations, or risk management,” she says.
As a result, the organization has revamped its discharge policies and processes more effectively. “It takes everyone from all of these disciplines to [transition] complex patients and to know you’re supported at the system level,” Carter says. “It prevents [case management] from working in a silo, and it also escalates areas of opportunity. We all know it’s not just case management that can facilitate a discharge; it takes a lot of different people coming together, making recommendations.”
The multidisciplinary team approach also results in empathy for case management practice. “In all fairness and honesty, I think it better equips our leaders across the organization in various departments for understanding the complex challenges we face every day,” Carter says.
The weekly reviews and policy improvements appear to have helped the health system shorten its long stays. “One of the things is we revamped our refusal-to-leave discharge policy. We found that our process wasn’t as robust, and it wasn’t very clear,” Carter explains. “We also created some behavioral contracts and processes and various types of pathways for how to manage patients’ behaviors.”
The team-of-leaders approach to supporting case management is a morale booster for case managers. “Case managers have been very surprised by the number of people who are working to solve some of the barriers and challenges that they experience every day,” Carter says. “They appreciate that senior-level leader engagement.”
Sometimes, leaders in other departments may not fully understand discharge barriers for complex patients because case managers handle it on their own.
“Opening up and discussing specific case examples has allowed people to have a better understanding,” Carter says. “For example, we used to get multiple calls from the chief clinical officer asking why a person has been in the hospital for so long and what is going on with them. Now that we’re working out of our silo and recognizing that we’re a system and are in this together, it’s eliminated some of our leaders’ frustration.”
Leaders in other departments understand why particular patients are unable to be transitioned, and they recognize discharge barriers for certain placements because they hear about these cases at the weekly team meetings.
“We know that being more proactive, escalating these barriers to discharge earlier, and having our weekly complex case management meetings and weekly length of stay meetings are all working together with our multidisciplinary team to improve our length of stay [performance],” Carter says.
Placing case managers in acute care and ambulatory settings to focus on transitions of complex patients could help shorten length of stay.
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