All Entries Tagged With: "patient flow"

Keep case management on your patients’ radar

Are you a case manager, social worker, or patient navigator who prefers to stay just below the radar screen, or do the patients whom you manage know you and know what to expect from you?

I’m a consultant who advocates for a better understanding of our roles, and a sister of a medically fragile man who has never met or spoken with the numerous case managers who coordinate his care. Here is a noninclusive list of tips to better promote and brand your role and functions:

• Engage patients and families. Before a registered nurse communicates to a third party, he or she must first engage and assess the patient to understand his or her unique story.
• Introduce yourself, and explain your role and what the patient can expect from you, I told patients that I was their WD-40. Case managers grease the wheels of the patient experience. I also told them that if I did not know an answer to a question, I would find someone who did.
• Create a brochure that describes what you do. Use simple words iand offer a brochure in the languages that reflect the populations you serve. This tool can also help other members of the healthcare team better understand your role.
  • Explain how you work with other members of the healthcare team, including social workers.
  • Explain how you work with episodic case managers, payer-based case managers, and any other liaison roles creeping into the organization.  .
• Give patients your contact information. Giving patients a business card is best, but writing your name and contact information on the whiteboard or providing it in via e-mail is even better.
• Follow up with patients. Case managers can be highly influential with respect to the patient experience. Visit patients just prior to their transition to ensure that all of the dots connected and follow up appointments are arranged. Every patient discharged to home should also receive a follow-up phone call. Some hospital administrators believe that staff nurses should make these calls.  I ask you, who better knows the post-acute environment, resources, and patient story than you?
• Be accountable. Follow through on what you say you will or can do. The best case managers I know don’t turn their pagers off at 5 p.m. or when they leave for the day. Remain available or explain who is available when you’re not.

This is not just a leadership issue to address, market, and brand. I believe it begins with each and every one of us. It is time to assertively establish our identity and be recognized for our influence on the patient experience.

What the EHR means to case managers

The Office of the National Coordinator for Health Information Technology (ONC) has released a final rule establishing a certification program for health information technology. The rule released June 18 describes the temporary certification program for electronic health records (EHR) and what organizations must do to be authorized to test and certify EHR technology, according to an HCPro.com article.

As a busy case manager you might think “well, that’s nice, but what is the big deal about the EHR?”

Most case managers have more work than they can handle and no time to think about their facilities’ adoption of EHR. Some case managers probably doubt that EHR will make their lives any easier.

Actually, case managers are invested in use of EHR. I want to share information compiled in a 2006 study by Eclipsys Systems entitled Eclipsys EHR Success Case Studies: Improved Operational Efficiency with an EHR. I don’t endorse a particular product, but I think this information demonstrates how EHR affects case managers.

The study found that EHRs helped:

• Reduce the need for full-time case managers while also increasing the number of reviews completed.
• Improve the process for managing concurrent denials because they allow clinicians to review medical records in their office or other locations within the hospital.
• Decrease the number of denials due to better management of avoidable days
• Improve staff effectiveness. Staff can access the entire chart and prioritize their workload.
• Enhance the ability to perform trend analysis by avoiding the need to manually enter data into an Excel® spreadsheet.

Users also commented that EHRs save time, reduce missed orders, provide better and safer care, and improve communication with physicians with legible notes.

While I wonder whether EHRs will reduce the need for full-time case managers, it would be wonderful if case managers had more time to focus on Medicare admissions, especially with increased scrutiny from government auditors. It also makes sense that legible records will reduce confusion and time spent verifying orders and outcomes. Also, EHRs with built-in utilization criteria may help providers reduce concurrent denials.

The ability to perform concurrent trend analysis with an EHR will allow case managers to actively prioritize their reviews and work more efficiently. Case managers could focus their time and energy on cases that need intervention most, which could reduce denials, improve quality of care, and increase cost effectiveness.

Case managers should be active participants in their organization’s process of reviewing and rating prospective EHR systems. EHR technology should facilitate communication between case management and computer-assisted coding software.

Case managers should be involved in all process improvement initiatives as payers move toward pay-for-performance reimbursement models. There are exciting opportunities for the practice of case management in the digital era.

Length of stay should not be a secret

Hospital organizations need to realize and act upon the fact that discharge planning begins at the time of admission. In 2007, MedPac (Medicare Payment Advisory Committee) told Congress that readmissions cost the government $15 billion a year (MedPac, 2007). Since then, there has been a strong emphasis placed on readmissions.

Estimating a patient's LOS at the time of admission helps establish how much time you have to complete the discharge plan

One of the first things we need to explain to patients and/or families is the patient’s expected length of stay (LOS). For the most part, patients want to come to the hospital, get treatment, and return to their prehospitalization setting. This is done through an interdisciplinary approach, which includes healthcare providers, the patient, and family members. In preparation for appropriate and thorough discharge planning, everyone needs to know how many days they have to complete the discharge planning.

Each hospital should track the Geometric LOS provided by Medicare, which can be used as a reference tool. Let’s say, for example, you admit a patient with chronic obstructive pulmonary disease (COPD) and the average LOS is 3.2 days. You can use this information to establish the amount of time the healthcare team has to implement an effective and successful discharge plan. Patients must be part of this plan and need to know what the average LOS is; however, patients must understand that each stay is individualized and their physician will ultimately determine their appropriate discharge time.

Our hospital gives a discharge flyer to patients upon admission. This flyer tells patients what they can expect in regards to discharge planning and their LOS. The flyer allows the patient and healthcare team to set mutually agreed upon goals. It also ensures patients feel confident about their healthcare at discharge. Since our hospital has a seven-day case management model, our admission case managers provide the flyer and the estimated LOS to our patients. They also discuss the LOS with the other members of the healthcare team so they can initiate the appropriate discharge planning.

Does your organization keep the patient’s expected LOS a secret or does it share LOS with the healthcare team, patient, and family?

Reference: Medicare Payment Advisory Commission (MediPac), 2007. Report to Congress: Promoting Greater Efficiency in Medicare. Payment Policy for Inpatient Readmissions. June, 2007.

One bad run-in shouldn’t define entire field of case management

Editor’s Note: I came across this letter to the editor that Nancy Sullivan, Director Case Management Massachusetts General Hospital Boston, submitted to the Boston Globe in response to an op-ed column that spoke negatively about case managers. I would like to thank Nancy Sullivan for allowing her letter to also appear on the Case Management Mentor blog.

In her op-ed “The ‘quicker and sicker’ exit strategy’’ (July 30) Deborah Schuss describes her family’s negative – and indeed, unacceptable – encounter with a case manager. One patient’s bad experience, however, should not define an entire field.

As trained and experienced nurses, social workers, and other health professionals, case managers work diligently and compassionately to ensure a safe transition for patients from the hospital to the next setting of care or home. Case managers serve as trusted guides during a period of uncertainty and change, helping families sort out details of ongoing care, and arranging for services after discharge.

As essential members of the patient care team, case managers advocate for the patient and family as they collaborate with physicians, nurses, and others. And while case managers help ensure that care is delivered in a timely and cost-effective manner, their decisions are driven by what is in the patient’s best interest.

I am privileged to witness each day the impact of case managers. One grateful patient wrote that his case manager “went out of her way to do detailed planning about my discharge, checked in with me regularly, was patient with all the questions I had, and reached out to my wife in addition to myself.’’ A family member expressed deep appreciation to a case manager who had spent extraordinary time arranging medical care in Florida so that a terminally ill young mother could travel to Walt Disney World with her children.

These are the case managers I know – true representatives of a profession I am proud to be part of.

Nancy Sullivan
Director Case management Massachusetts General Hospital Boston

What about those hospital discharges?

Who should be doing the discharge planning and who should be working with the patients and families to make sure the goals set for the patient are being achieved? Who is developing the discharge plan? These are all great and very important questions. Discharge planning should begin as soon as the patient sets a foot inside the hospital, whether that is just to the emergency room or is placed as an observation patient or inpatient.

This is another great reason for the admission case management model. The admission case manager begins the discharge assessment right at the time the patient is either placed in an observation or inpatient status. If the patient is discharged from the emergency room, our social worker works with the emergency room staff, patient, and/or families for appropriate discharge planning.

The seven day a week admission case management model at my hospital is guided by Imogene King’s Theory of Goal Attainment. This theory of goal attainment implies that nursing is to help people achieve, maintain or restore health through the mutual setting of goals (Hood & Leddy, 2006). The nurse and/or social worker and the patient come to agreement on a mutual goal to achieve; this brings the patient to the forefront and the most important being. There is interaction of the nurse/social worker and the patient in the appropriate environment that is most conducive of achieving the goal. Once the goal is agreed upon and set, the next step is defining what steps will be taken to reach the desired goal. Case management as it evolved became a process of assessment of patient needs (goal setting with the patient and or family), planning of care, arranging resources of services and ongoing coordination and evaluation of the care being provided.

Our model is successful because of teamwork. Our case managers and social workers work together with the patient and families as well as the other hospital disciplines, through interdisciplinary rounds to ensure that everyone is working toward the same goal for discharge.

Discharge is more than getting the patient out of the hospital door. It is making sure that the patient is going to a safe, agreed upon place with the appropriate resources available and in place. Successful discharges reduce those unwanted readmissions.

Reference:

Hood, L. J. & Leddy, S. K., (2006). Conceptual bases of professional nursing, (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

What do hospital case managers do, anyway?

This is a question frequently asked by patients, family members, physicians, and other members of the medical staff.

Many people think that case managers are discharge planners, and that the only time a patient needs a case manager is when he or she has discharge needs. Case management is much more than that. It is important that we make sure that, not only do patients and families know what case management is, but that the nursing staff members know also.

Case managers work in forces behind the scenes, much like the crowd of people in the Verizon commercials. Case management is a hidden resource for patients. Often, the case managers work in the trenches, with their heads in charts, communicating with an interdisciplinary team of healthcare professionals to make sure that the patient is moving smoothly through the continuum of care, and there are no delays or detours in their care. This is usually an unknown aspect of case management.

Hospital personnel and the public need to be aware that case managers are advocates for all patients; they ensure that their healthcare facility and professionals are doing what is truly right for the patient, in the right setting, receiving the most appropriate care, and in the most cost-effective manner. Case management follows the patient’s plan of care to make sure that it is appropriate and timely, that their hospital admission status is appropriate, that their discharge planning is initiated, and that goals are set to meet the discharge plan. It is imperative that the case manager build a relationship with the patient and their families in order to reach a mutual goal of discharge.

It is also important for the bedside nurses to know that case managers are an excellent resource for them in planning the patients’ care and goals. One thing I did at our institution while we were redesigning our case management model was to do a mandatory in-service to nursing staff on how case management affects not only patient outcomes, but the financial outcomes for hospitals.

At our institution this year, we included a station on case management and interdisciplinary rounds at the nursing annual competency testing. Case management had a display booth with information about what case management is and the importance of interdisciplinary rounds. We also had a test for the nurses to complete. The comments we received from staff were very interesting.

Does your institution do anything like this? Are you confident that nursing staff members truly understand what case management is?

And one more important question: Do your physicians really know what case management is?

Optimizing patient flow to protect against the RAC

Waits, delays, and cancellations are so common in healthcare that patients and providers have come to expect waiting as part of the care process. But poor patient flow can have seriously adverse effects on patient outcomes and your facility’s bottom line—and can even increase your susceptibility to RAC audits.

According to Kelly Cooke, MSN, RN, the director of clinical resource management, social work, and documentation improvement at the Hospital of the University of Pennsylvania, part of maintaining optimal patient flow is placing patients in appropriate level of care and creating a system that guards against readmissions.

“If you can initially place your patients in the appropriate level of care, this will enable your facility to have a very successful RAC audit,” says Cooke. In addition to up-front processes, she recommends creating strategies to prevent unnecessary readmission.

In the April 27th HCPro audioconference, Optimize Patient Flow Through Case Management: Maintain Revenue Integrity and Joint Commission Compliance, Cooke, along with patient flow experts Derenda S. Pete, RN, MBA, and Brooke Wollenberg McDonnell, MBA will discuss how Hospital of the University of Pennsylvania created 25 virtual beds and have created a system that not only keeps them RAC ready, but has allowed them to gain, on average, four hours on each discharge. The audioconference will also offer strategies for dealing with inappropriate admits, information on how to manage the uninsured and underinsured, tips on how to collect, analyze, and distill data to improve outcomes, and suggestions on how to communicate with physicians on appropriate admission criteria.

Audio update: Managing LOS

As pay for performance and Recovery Audit Contractor investigations gain a greater bearing on the amount and expediency of reimbursement, managing length of stay (LOS) has become even more crucial for case managers. While responsibilities of case managers expand, an important measure of success continues to be managing LOS.

Many case management departments look at meeting a target number of days a patient stays at a facility, however, evidence has shown this may not yield the best outcomes when looking to manage and improve LOS. Inova Health System in northern VA, has had immediate and sustained success in reducing LOS through targeting clinical milestones. Its focus has been on improvement of the patient’s condition and minimization of avoidable complications, resulting in improved quality of care and a proven reduction in LOS.
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