The Changing Face of Hospital Case Management
BY MARY MCLAUGHLIN-DAVIS, DNP, ACNS-BC, NEA-BC, CCM
Case managers in the acute care setting today are faced with a plethora of healthcare changes. It is true that they are not alone, as everyone working in a hospital setting faces challenges. Patient care is moving to the ambulatory care setting, and we are seeing a shift of the sickest and frailest patients occupying the majority of beds in acute care. As we all know, there are consequences to every action, and this shift creates a need for even greater efficiencies across all care settings — but it is felt strongly in acute care.
We know the old model of combined discharge planning and utilization management (UM) is not sustainable. There are many obvious reasons for this, among them being the complexity, detail and intensity of utilization management. The criteria and levels of review and appeals have made UM a specialty in its own right. It is tied to financial outcomes and does not require any patient contact. UM began as a corporate compliance and financial function, and that is where it belongs. Discharge planning is also a relic and is not relevant in today’s world of value-based care and population health (Daniels, 2017).
An estimated 5 percent of the population use 50 percent of healthcare resources. The 5 percent are patients presenting with comorbid medical and behavioral conditions. In fact, 29 percent of individuals with a medical condition have mental health comorbidities (Goodell, Druss, Walker, 2011; Perez, 2017). These are the patients in our acute care hospitals, and a case manager tasked with UM is able to give only an acknowledgement of the discharge, or arrange a post-acute service that may not be feasible, affordable or effective.
Hospital nurse and social worker case managers in today’s acute care setting need to collaborate with the patient to design a plan central to the patient’s goals. The plan must be agreeable to the patient, reasonable to execute and congruent with the CMSA Standards of Practice. The case manager is the advocate for the patient, and she will not allow a discharge to occur that is not safe, a question go unanswered or a medication prescribed that is unattainable for the patient’s level of understanding, income or way of life.
Many hospitals’ leadership teams recognize the value of professional case managers. They understand the importance of linking patients from acute care to ambulatory care. They appreciate that case managers, after a thorough assessment and planning with the interdisciplinary team, transition patients to home care, a skilled nursing facility or another acute care specialized hospital. Today’s acute care case managers, now more than ever, must follow the CMSA Standards of Practice in their own practice. There cannot be a rote discharge plan for a disease or a diagnosis.
Hospital case managers must be able to articulate the purpose of care coordination and how as a case manager they are willing to provide this to the acute care population. Case management leaders must articulate this purpose to the hospital system executive team and offer a path for a case management restructure within the system, if that is warranted. ■
Daniels, S., (2017). The Choice is Yours Care Coordination or Discharge Planning. Phoenix Medical Management, Inc., Pompano Beach, FL. http://www.phoenixmed.net/killing-our-young.html. Retrieved Jan. 1, 2018.
Goodell, S., Druss, B. G., Walker, E. R., & MAT, M. (2011). Mental disorders and medical comorbidity. The Synthesis Project. Robert Wood Johnson Foundation.
Perez, R. (2017). The CMSA Integrated Case Management Program. Rebecca Perez CMSA, Little Rock, Arkansas.
Mary McLaughlin-Davis, DNP, ACNS-BC, NEA-BC, CCM
President, CMSA 2016-2018
Dr. McLaughlin-Davis is the president of CMSA. She has been a certified case manager since 1993; she is a clinical nurse specialist for adult health and the senior director for care management for Cleveland Clinic, Avon Hospital.
Pictured in photo: Shelley Mason, MSN, CNP, RN-BC; Cortney Weaver, RN, and Tami Maggard, BSN, RN, CCM (CMSA member), Cleveland Clinic, Euclid Hospital