Where is Hospital Case Management

Dr John Banja's mantra that "advocacy is the case manager's primary ethical obligation" does not often get translated into case management practice. And when we fail to consider those obligations, every stakeholder suffers.

Legendary football coach Vince Lombardi once said, "Perfection is not attainable, but if we chase perfection, we can catch excellence."  The pursuit of excellence in hospital case management has a multiplicity of components, many of which have been addressed in previous blog posts, our LinkedIn NextGen HCM group, and the numerous letters, articles, and books that we've produced.  But we must continue the progress, in a number of key areas. Outlined below, are two issues:

1.  The Need to Focus on Outcome Metrics -   Because of the increased attention dedicated to the outcome agenda, an entire subset of businesses have cropped up over the past decade to rate and compare healthcare providers.  But the disparities in findings are confusing to consumers and to many of us in the industry.  Similarly, outcomes for care management are often confusing - if reported at all - because they seem to be largely focused on discharge planning and utilization review surrogate metrics such as length of stay, how many pre-admission HINN letters were issued, or the volume of CC-44s. Despite the pressures to report on these parameters, every care management program needs to stay focused on its own internal pursuit of practice excellence and patient centered outcomes. The focus needs to be ongoing rather than a project for the month and requires setting strategic priorities, the realignment of case management structure and investment in education, training and skill development. 

2.  Partnering with Selected Patients -  A core value of patient centered care management is its focus on engaging patients and families in the care process. Discussions around patient engagement have been going on for decades, but, in my experience, care managers have not modified their practice processes, or changed their structures to make it happen. There are three articles that I keep going back to that provide evidence of the failure of the hospital care manager to engage the patient and advocate on their behalf.

In 2012 Dr John Banja wrote about a workers compensation case manager who "didn't seem to make any attempt to coordinate thoughtful communication among team members" and "hardly seemed to do anything resembling case management functions." Instead, the case manager's "primary concern appeared to be the [worker] returning to work on the day one of his physicians stipulated."

In an aricle by Anne Jackson written that same year, she relates her experience with her mother's hospital case manager who introduced herself "and immediately started talking about nursing homes."  Ms. Jackson eventually 'fired' the case manager and made contact with another one who exhibited a more patient-centered "can-do attitude."

Similarly, an article in 2013 by Judith Sands relates her experience when her husband's 79 year old aunt was rushed to the hospital.  Five case managers later with no evidence of any coordination, "and no follow-through communication on unresolved issues," Ms Sands contacted the program Director and spoke with the director's secretary to relate her disappointment and dissatisfaction. "No return call was ever obtained from the case management director."

These horror stories underscore the failure of many hospital case management programs to fulfill their professional obligations. From one patient having multiple case managers while in the ICU, to the care manager who defined her role as a discharge planner, and the worker's comp case manager who specialized in "directing the flow of various documents...but didn't do anything of a substantive, case management nature,"  these stories relate the failures of a functional model of hospital care management and have no future in today's value based, patient centered environment.  

My perspective is shaped by my role as a consultant engaged by hospital execs to transform functional care management models to value based programs and by my past life as a hospital administrator.  My views are also guided by my exposure to hospital care management staff members and communication with a broad selection of physicians, patients, and clinicians in hospitals across the country. Like Dr Banja, I have "tremendous respect for what aggressive and client-centered case management might be able to do."  These stories show that we have to do it now.

 1. John Banja.  If you don't have a case management plan, are you doing case management? CMSA Today,  Issue 2, 2012

2. Anne Jackson.  A Daughter's Tale: A personal view of case management. Collaborative Case Management. Nov/Dec 2012.

3.  Judith Sands. Where Was Care Coordination?  CMSA Today. Issue 8. 2013.