Are We Killing Our Young?

Every day, in hospitals across the country, there are people holding the title case manager, care manager, care coordinator or something similar who are performing multiple tasks necessary to plan and arrange a patient's discharge. Many of those same people are also charged with trying to protect revenue integrity by performing utilization reviews. Do these responsibilities constitute the professional practice of case management?

My friend and colleague Anne Llewelyn recently sent me a copy of an email she received from a young woman looking for a new clinical challenge. After reviewing information on trends in healthcare while pursuing her master's degree, she zeroed in on case management . To gain experience, she applied for a job in her hospital.  Here's her letter - reprinted with her permission: 

Hi Anne,

I'm very confused about an experience I had when I interviewed for a case management position at the hospital where I work earlier this week. I wanted to run this by you and get your thoughts. 

I interviewed with the Case Management Director and two of her case managers. At the beginning of the interview the director asked me to tell them what I thought the role of the case manager was. I told them that case managers helped people navigate the labyrinth of the medical system and that they advocated for helping people achieve their optimum level of wellness and functionality. I said they put the nursing process into action by assessing, planning, implementing, coordinating and evaluating options and services to meet people's comprehensive health needs.

The director seemed to look a little amused so I told her about a personal experience I had last year when my father was diagnosed with a terminal illness. I explained how my father (and my mother and I) quickly lost our identity and our voice as we tried to navigate through the system. I remembered literally crying and begging our oncologist for the help of a case manager. I was told that their case management department wasn't up to par and that he (the oncologist) was the only person we needed. (This was at XXXXX XXXXX in Miami Beach!).  The director asked me, "If [you had access] to a case manager, what exactly would [you and your family] ask from her?" So I explained everything that we needed, how we were lost and weren't getting any help during this nightmarish experience.

After I finished, the director said exactly this to me. "That is not case management. That is not what we do." I was actually stunned. I asked her to explain what they did. It sounds to me like what they do is solely discharge planning and utilization management and review. The director told me that she would have offered me the job because I had the right personality for it and I had great experience, but she said that I would hate what they do and be very unhappy and she would be doing a disservice to me and to them by placing me in that position. She did tell me she would be interested in being a preceptor for my Master's program and that I could shadow the UR nurses and sit in on some meetings. I was grateful, however, I left without a job and with much confusion about case management. I'm feeling like I might should put my master's program on hold and try to get some experience in case management first so I know what it's really about. I'm very confused! Am I wrong about case management? Am I being too idealistic? I sat in on CMSA's webinar yesterday afternoon and my thoughts on case management were validated.

 I'd love to hear what your thoughts are. Thank you for listening!

My modified response to Anne follows:: 

Good morning Anne - always great to hear from you.

Your friend Leah has encountered the same narrow thinking about case management that I find in hospitals across the country.  It's no secret that I blame this squarely on our professional organizations since I write about this - speak about this - blog about this issue incessantly.

Case management has morphed into a compilation of several hospital services provided by the hospital typically including utilization review, care management/care coordination, appeal/denials, PARC services, social counseling, etal.  And among these care coordination is the hallmark of 4th generation models.

The only problem is that too many hospital leaders are mired in the past.  As you well know, functional models were introduced in the 1990s by management engineers who responded to the CEO's call for quickly reducing costs to survive in the PPS reimbursement world. As a result, and with a little help of fairy dust, the SW dept and the UR dept were merged, it was renamed case management, but the staff continued to perform the tasks associated with Discharge planning and UR.  "Case management" as originally intended was lost in the shuffle.

With the rapid changes in the marketplace, innovative program leaders are educating C-suiters about care coordination across the continuum and we are seeing glimpses of 4th generation models where the focus is on generating improved patient centered outcomes for selected high risk patients.

Leah's experience is not unique. There are many case mgmt directors who define 'case management' as discharge planning and UR. They appear to lack the confidence or the talent to educate the C-suite about the future and can't relate the changes in the environment with necessary changes in model and practice.

It's one thing to recognize that hospitals have different cultures, needs and preferences and may organize their case management 'programs' based on those characteristics….but the practice of "case management' should be consistently practiced across the board….if you are going to use the title case or care manager then you better understand what care coordination is all about and you should be consistent in your practice.

Otherwise, do not use the title case/care manager.  It's no wonder there are so many vacancies in hospitals across the country…who in the world would want these jobs….overburdened with tasks, understaffed when disillusioned and overworked staff leave, and expected to meet goals that are beyond reasonable.

I applaud Leah for recognizing the challenge but we need more Leahs to let the world know that they don't want to sign up for discharge planning and UR --- they want to offer their professional talents and clinical knowledge to advocate for those patients who lack a voice but who are desperate for the  insights, information, and coaching that a patient centered care manager can provide!!

Shortly thereafter, I received this note from Leah:

Hi Stefani,

Thank you so much for your response and sharing your insight. Actually, it was extremely refreshing to know that I am definitely on the right track. I was honestly shocked when, after hearing my definition, this Director of Case Management told me that was not case management. My heart sunk and I thought maybe I was way off base.It definitely threw me for a loop and made me question what I thought I really wanted to do. I think I have what it takes to be a great case manager. And I believe that I have a unique (and necessary) perspective from my experience with my father that will help guide my way.

Leah will pursue her masters and I'm confident that she will become a great patient advocate in the field of case management. But how many other Leahs are there.....Experienced clinicians who know what care management should be but are stymied by program leadership mired in the past and a executive team with little inclination to disrupt the status quo.

There are many organizations with brilliant leaders who keep up with the changes in the marketplace, know the pressures on the hospital and medical staff, and understand the patient's financial constraints and social challenges and who look to the literature and conferences and webinars to discover how their peers are managing the rapid pace of change. Care managers must be positioned to serve as the primary advocate to our high risk patients to promote a safe, effective, and cost efficient journey across the continuum.  Unless we do, we will continue to read the stories like the one we published last week.

I believe our professional organizations owe it to the Leahs of the world to affirm their support of pro-active care coordination as the essence of professional case management.  What are your thoughts?  Email me at daniels@phoenixmed.net and thank you.