Learning from Corporate Models of Case Management
October 1, 2022 6 minutes read
By Jeni Miller
As healthcare systems continue to merge, and larger systems acquire smaller ones, case management models need to adapt to accommodate the changes in size and structure.
For example, Atrium Health and Advocate Aurora Health announced a plan in May to merge into a combined system consisting of 67 hospitals with a shared 158,000 employees.1
In December 2021, Intermountain Healthcare combined with Colorado-based SCL Health, creating a system of 33 hospitals employing more than 58,000 caregivers.
As of 2019, the top 10 health systems by number of staffed beds included:3
- HCA Healthcare: 211 hospitals; 42,190 staffed beds;
- CommonSpirit Health: 203 hospitals; 23,269 staffed beds;
- Universal Health Services: 172 hospitals; 20,607 staffed beds;
- Ascension Health: 125 hospitals; 16,989 staffed beds;
- Tenet Healthcare: 84 hospitals; 15,890 staffed beds;
- Community Health Systems: 109 hospitals; 14,131 staffed beds;
- Trinity Health: 58 hospitals; 11,028 staffed beds;
- Providence St. Joseph Health: 57 hospitals; 10,345 staffed beds;
- Kaiser Permanente: 43 hospitals; 9,625 staffed beds;
- LifePoint Health: 86 hospitals; 9,504 staffed beds.
Chicago-based CommonSpirit Health became the second-largest health system in the United States after it was formed through the alignment of Catholic Health Initiatives and Dignity Health. Dana Farley, RN, MBA, CCM, system senior vice president of patient care coordination, says the nonprofit health system includes “more than 1,000 care sites in 21 states, serving 20 million patients in big cities and small towns across America.”
Merging Systems, Creating a New Model
Before the 2019 merger, the two health systems used different case management models.
“The legacy Dignity Health system used the dyad model, which consisted of case managers and assistants performing medical discharge planning, patient progression, readmission avoidance, and utilization management,” Farley says. “The clinical social workers performed crisis intervention, complex discharge planning, and readmission avoidance.”
Meanwhile, Farley says the Catholic Health Initiatives system used the triad model, by which case managers performed everything except utilization management, which was handled elsewhere.
Deciding which might work best for the new CommonSpirit Health system could have proven challenging, but leadership worked toward a comprehensive approach that included these four model components:
- Utilization management/concurrent denials. This consists of RNs with oversight of admission and concurrent medical reviews for payers, both governmental and private, and real-time denial management in conjunction with physician advisory services. Care coordination assistants help the team with payer communications.
- Care coordination/discharge planning. RNs perform medical discharge planning, perform readmission avoidance, and communicate with physicians and family on the plan of care. Care coordination assistants also help the team.
- Psychosocial assessment/discharge planning. Social workers focus on patients with psychological or social needs that can affect their physical well-being. They also perform complex discharge planning as needed.
- Care transitions coordination. This consists of clinicians who focus on helping the patients move from the hospital to post-acute care. The clinicians monitor patients to prevent readmissions.
These components are “then supported by divisional care coordination leaders who support the local hospital leaders and staff with removing barriers and serving as subject matter experts,” Farley explains.
CommonSpirit Health added another layer of system support services for their whole care coordination model, including:
- A social work and vulnerable populations director who acts as a liaison between the acute and ambulatory care coordination teams for the most vulnerable populations. They collaborate with community partners and ensure patients are connected to those necessary resources. The director also serves as a subject matter expert for the social workers throughout the enterprise.
- A care coordination education department that teaches the care coordination employees, including the leadership staff. This allows for consistency in training, and helps monitor performance across the enterprise. They also train the staff in leadership and professional development skills as needed.
- A care coordination operations department that consists of project managers and an operational leader to help run meetings and special projects.
- A care coordination analytics department that provides leaders with information dashboards necessary to run their teams. They also help leaders analyze reports and metrics to identify trends for process improvement.
- A care coordination regulatory review department that audits processes to ensure compliance with regulatory requirements. They also monitor compliance with the system’s guidelines, policies, and procedures.
While these layers might not be necessary for a smaller hospital system, they could take the pressure off a smaller team or a team whose members handle many tasks rather than managing one or two focused tasks.
For Farley, this comprehensive model has “proven to be best for CommonSpirit Health. In our organization, the corporate case management team has oversight of the divisional and local case management departments. This allows for standardization of policies, job responsibilities, alignment under one strategic plan, working toward the same goals and metrics, visibility into whether or not we are adhering to the regulatory guidelines, and it has the ability to allow for continuity in educating and training the staff.”
As with any model, “communication is key to managing a team efficiently and effectively across the whole enterprise,” she notes. “With so many processes happening every day among all of the departments and care sites, there’s the potential for misalignment and for things to go wrong.”
Likewise, building relationships with key stakeholders and departments across the organization is a significant contributor to the success of managing a large enterprise.
For other health systems of similar size or characteristics, Farley recommends a realistic approach that recognizes one person — or even one small set of people — cannot manage the entire process on their own.
“In today’s environment, the case manager/social worker is expected to be responsible for a whole lot of things, [like] progressing the patient through their stay in a reasonable time frame, discharge planning, addressing psychosocial concerns, submitting timely clinical information so the patient’s stay is authorized, setting up services that patient needs for the next care setting, and a whole host of other duties,” Farley explains. “It is beginning to be almost impossible for one person to address all of the duties effectively. Therefore, we had to move to a model where the care coordinator/social worker/care transition coordinator could focus on providing the best quality care possible in the areas that they support.”
There is good reason for the extra effort that health systems like CommonSpirit Health put forth. When a case management department in a large, corporate hospital system does not use the appropriate model, it is increasingly likely that “you will see a lack of consistency and efficiency in care delivery,” Farley notes. “You could also experience an increase in length of stay, quality of care decrease, increase in claim denials, and readmission of patients. When this occurs, it is, unfortunately, felt by the patients and families we serve.”
However, when conducted properly, the case management model can serve the hospital system and its patients well. For CommonSpirit Health, this scenario has played out more than once, confirming the model is working as it should.
“The care transition coordinator received six escalations from the care coordination and social work services for assistance with home health placements,” Farley recalls. “She reached out to home health providers to determine the barriers to their acceptance and found some common themes. These included additional clarification on the skilled services being requested, a lack of a primary care physician to support continuing orders, frequent long-term IV antibiotics administration, complex psychosocial issues, and an unusual payer for the area. The coordinator reached out to partnering home health providers and outlined the complex issues. She provided feedback to physicians on the elements the home health agencies had identified as essential to accepting the patient. She also worked with a local infusion company to help with staffing the frequent infusion of IV antibiotics. The escalated case was accepted within 24 hours by a contracted provider in the Post-Acute Narrowed Network.”
Health systems should be sure to use the right governance model to help support case management, which can make a significant difference in the success of the program. Likewise, the department “should have care coordination committees that staff and local care coordination leaders can be involved in,” Farley says.
These committees facilitate networking, provide a place for exchanging ideas, foster innovation, and suggest ways to enhance work effectiveness.
REFERENCES
- Advocate Aurora Health. Advocate Aurora Health and Atrium Health to combine. May 11, 2022.
- Loeb S. Some of the biggest healthcare mergers and acquisitions of 2021. Vator News. Dec. 28, 2021.
- Definitive Healthcare. Top health systems: Mergers, acquisitions, affiliations. Updated September 2019.
As healthcare systems continue to merge, and larger systems acquire smaller ones, case management models need to adapt to accommodate the changes in size and structure.
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