Case Management Society of America

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Insight Into a Successful Case Management Department

BY CONNIE COMMANDER, RN-BC, MBA, CCM, ABDA, CPUR

At the Past Presidents’ Panel this June in Las Vegas, all the participants were asked specific questions, based upon our own expertise and experience. With our multiple years
‌of hands-on leadership, we realized that many of the attendees might like to hear our perspective in building successful case management departments, no matter the venue.

My specific expertise has been in multiple settings, but for this publication, I wanted to share some insight into acute care case management departments.

I have consulted in multiple acute care settings across the nation. There are several things that I feel lead to the success of the department. One critical aspect is to whom in the C-suite the department reports directly. Without the support of this level of administration, the department could be set to fail. I have reported through the nursing officer, the chief financial officer and the chief medical officer at any one time. My preference is to report through the CFO directly, with strong dotted lines to the CNO and the CMO.

SUPPORT FROM ALL IS CRITICAL TO THE SUCCESS OF IMPLEMENTING OUR PLANS!

Case management teams are critical in developing credible alternatives that are safe for our patients, quality focused and financially responsible to all. The most beneficial path to submitting some very challenging plans has been by utilizing a cost analysis that covers:

  • What is involved in the plan?
  • Why is it beneficial for the patient and the facility?
  • Cost to implement
  • Savings anticipated
  • Resources investigated
  • Resources that are available to the patient

By performing this basic of business tools, I have been able to gain approval by the entire C-suite leadership for some very aggressive and “outside of the box” plans of care, leading to positive outcomes for the individual patient.

After gaining a strong working understanding of the reporting structure of the department, I find it very helpful to interview every case manager team member. Without this direct feedback from the team members, you will lose valuable insight into key areas of concern. While you are at it, don’t forget to ask them what is working well. This process will save you valuable time and help you to gain critical insight from the team who have been in
the trenches.

Although I have not always had this work out for me, I find my strongest departments have included social workers in the same department. My consistent challenge has always been to include the social worker and the RN team member as equal case managers within the department. I highly recommend to senior leadership that they are performing the same vital job expectations and should be of equal pay as the case manager. Both come to the table with obviously different strengths, but all are needed to complete a credible plan of care.

Developing strong team members within the department helps to share resources and time to focus on the needs of the patients. Included in this team should be non-licensed medical personnel who can assist both the RN case manager as well as the SW case manager.

Having the individual licensed members work to the full scope of their licensures is invaluable. Freeing up the RN and SW to be able to spend their time assessing individuals and interviewing resources is much more meaningful than having our professional team members spend time on the phone, setting up appointments or transportation or reaching out to the health plans for approval.

I know that many times we are our own worst enemy, because I have heard it is just easier to do it ourselves. Although that may be true in certain situations, the more complex our patients are, the more complex our plans of care become and the more time to develop and implement. These are the cases that we must use or own department resources to save valuable moments, freeing us up a little at a time to focus upon the next patient.

In this day and time, there are still departments that are focused more on the utilization review process. I challenge these departments to have the job function of reviewing for approval given to individuals such as LVNs or LPNs who can team up with the RN case manager for questions as required. Think about working with your key payer source to review with your team what they actually require, by diagnoses and frequency. This can save you time in rather large buckets for your team.

Other critical aspects and recommendations I have involving routine utilization review processes include:

  • Giving the entity who needs the review information direct access to their patients. Eliminating the need for reviews to be completed by the case management team members unless there is a disagreement.
  • Working closely with IT departments to make this a viable option.
  • Consider using artificial intelligence software programs that access and highlight the specific patient information and gather that in a timely manner. Identifying needed medical trends within the individual patient’s chart is a huge time-saving process. It is also extremely beneficial in securing authorizations when an appeal is necessary.
  • Technology is critical. Using iPad, laptops etc. vs. completing reviews via manual processes is critical.

I believe it is extremely beneficial to hire experienced individuals to fill the social worker and RN case manager positions. I have always tried to hire individuals with varied backgrounds. This little thing builds you a strong internal resource department. Having case managers with varied backgrounds on our teams allowed others to learn from them in fields where they may not be as experienced. As I did this, I also included outpatient-focused individuals who could share with the team the workings of areas outside of the inpatient arena.

Building strong working relationships and having a strong collaborative communication opportunity with skilled units, home health care and hospices (to name just a few), keeping open lines of communication fluid and focused upon the needs of the patients help the case manager to address issues and opportunities that can be identified. I would recommend routine meetings with these frequently utilized resources to be successful.

Professional development is critical to our success. Allowing our team members to participate and attend routine continuing education is such an important aspect. Many times, giving the individual time away is all it takes to get needed current information shared with the team. By not allowing participation in continuing education opportunities in our geographic practice areas, we risk the teams not being aware of the latest and greatest as things are being developed.

I know that senior leadership is so very hesitant to not allow outside vendors into the facility or even our team members to attend local educational events for risk of conflicts of interest, but I remain firm that our team members need to have this type of educational opportunities routinely available. It is the responsibility of all of our teams to be aware of any misconduct that might arise and present itself, and report to the case management leadership for review.

These are just a few of the critical aspects of developing a successful, professional team for your case management department. It is not a complete picture but one that is inclusive of some of the critical items that may be overlooked. Using experienced professionals, training those who are not as experienced, utilizing technology as much as possible to do routine jobs and carving out tasks that do not require professionals to perform will help you build a strong base to work from.

I hope this is beneficial to you as you move forward with your departments. The suggestions I have included are the ones I am frequently asked about from others in our field.

I will leave you with some thoughts:

  • We are a strong professional group inclusive of multiple other professional members.
  • We must be strong in our communication skills.
  • We must be able to think outside of any box.
  • We must be visible to all members of the team.
  • We must be able to develop and present credible, appropriate plans of care.
  • We are strong patient advocates with strong communication skills.
  • We are the “glue” or the “center” of the team who stand with our patients to help them be successful in working their proposed plan of care.

Good luck to all, and thank you for the opportunity to share my insights.

Connie Commander, RN-BC, MBA, CCM, ABDA, CPUR
As owner and president of Commander’s Premier Consulting Corp., Connie is focused upon the advancement of case management and medical management in today’s healthcare environment. Previous experiences have been in health plan- and hospital-based case management programs, physician networks and facility-based departments located in Texas and Illinois. She has held numerous management positions focused upon the implementation of and the merging of CM, QM, UM, DM and risk management. She has experience as an administrator for an independent physician’s association in the Chicago area, and multiple years experience in management, contract negotiations and measuring outcomes based upon case management interventions.

She currently educates case managers across multiple settings to develop and implement a collaborative practice of case management and care coordination throughout all delivery of healthcare venues. She believes that the key to improving individuals’ health outcomes begins with preventive medicine and continues with individual patient-centered treatment teams. She embraces a Behavior Change Model to educate individuals and support them to move toward effective self-care. Connie views collaborative models, integrated healthcare delivery systems and effective transitions of care as critical components for care coordination.

She is a national speaker and author and continues to network and mentor others in the field, both on national and international settings. She has participated in multiple advisory committees and professional associations to further her education and networking abilities. She has been awarded both the National and Houston Chapter Case Manager of the Year award. She has held several national board positions, with CMSA, including national president of CMSA for 2006-07. She sits on the NASW Foundation board and continues to consult in case management in multiple venues.

Image credit: ETIAMMOS/SHUTTERSTOCK.COM

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