by Stefani Daniels, Managing Partner
Published on Nov 03, 2015

Hospital Case Management was never meant to perform the discharge planning and utilization review functions that prevails in many acute care hospitals today. These functional models are heavily dependent on routine chart audits and has undermined our primary purpose as patient care advocates. When multiple tasks are heaped onto the shoulders of hospital case managers, they do none of them well.

Indulge me for a moment and travel back to a hospital unit of 1983.  The organization is in the midst of preparations for the introduction of the prospective payment system.  At medical staff meetings, the CFO is explaining how the new DRG system will work; hospital associates participate in mandatory in-service programs; and nursing educators are going from unit to unit to make sure everyone understands the implications of a fixed rate payment system.  And in New England Medical Center (NEMC), Karen Zander and her associates were developing a new case management nursing model. “The conceptual model is on outcomes; it is a synthesis of primary nursing care and nursing process and introduced critical pathways and case management plans as essential guides in structuring the episode of care”   (Financial Management for nurse managers Janne Dunham-Taylor, Joseph Z. Pinczuk, p. 637). Zander’s development of critical pathways was the prescient precursor of today’s evidence based protocols and they were used as a method for structuring, coordinating, and assessing the patients progression of care (my italics).Variances from that progression of care were documented just as progression of care delays and potential avoidable days are documented and quantified today.

Now travel with me to the years 1986 – 1990. The full effect of the prospective payment system is felt by hospitals across the country. Organizations that carefully prepared knew that resource utilization trends and lengths of stay had to be constrained so that a profit margin and financial stability could be realized. The majority of hospitals were successful in this endeavor, but many weren’t and over 1000 hospitals closed during this period through bankruptcies, acquisitions or conversions.  There were also many hospitals that scrambled to survive and brought in management engineering teams to quickly reduce costs, consolidate services, and eliminate staff.  Having read about the success of Zander’s team at NEMC, these management engineering consultants suggested merging utilization review departments with social work departments to create case management departments.  The practice of case management as developed by Zander got lost in the shuffle.

Case management departments no longer were involved in structuring, coordinating, and assessing the patients progression of care but rather adopted the activities of their constituent components:  Utilization review and discharge planning.  Utilization review nurses who audited charts to determine medical necessity for acute level of care continued to do so.  However, the social workers who for years, had been the nurses’ ‘go to’ people for facilitating nursing home placements, expanded their roles. 

Before case management departments were created, nurses were still responsible for creating plans for their patients’ discharge and referred cases to the social workers if the plan included a transfer to a nursing home.  However, in the evolution of case management models, social workers slowly assumed greater discharge planning and arranging responsibilities to the point today where hospital nurses rarely get involved with the discharge process. 

There are many writers who cite the dramatic staffing cuts as the source of this shifting social worker paradigm.  Lower lengths of stay, it was thought, would not be conducive for social work practice and so their positons were eliminated. To salvage their FTEs, the social workers had to demonstrate their essential contribution which is how they became the discharge planners that exist in many hospitals today.  In hospitals where social worker positions were totally eliminated (and there were many), the UR nurses, now known as case managers did both the UR and the discharge planning.  Unfortunately, they did neither very well.

Which is how we got to where we are now.  To state in your article “Do Collaborative Case Management Models Decrease Hospital Readmission Rates Among High-Risk Patients?” that “the discharge process is a function of the case management department” is to disregard the purpose of case management practice as originally intended.  In fact,  your citation of the modified brokerage case management model by Rapp & Goscha 2004, which states that case management includes “essential elements such as assessing client's needs, identifying efficient and effective resources, advocating for the client, the payer, and the case management program, and monitoring delivery of services” is closer to the Zander model than it is to the functional model of UR and discharge planning that the management engineers proffered in the late 1980s.

In my experience, disregard for the core attributes of a contemporary case management program as promulgated by the CMSA and ACMA has been cited as the reason for reports of burn-out, absenteeism,  position vacancies, and hefty attrition rates.  Contrary to your statement that “case management models vary in detail, but overall the main objective is to deliver an approach to discharge planning that is patient-centered and collaborative,” I believe that the overall objective is to advocate for selected patients (hospital case management is too expensive to provide to all and not needed by most) to ensure that they get the right care (evidence based, safe, appropriate for their reason for admission, adheres to their preferences, is not wasteful or potentially harmful, etal), in the right place (“hospitals are dangerous places to be when you are seriously ill”), at the right time (efficient and effective delivery care). Enabling primary nurses to distance themselves from any discharge planning responsibilities is to do a disservice to the profession and their patients.  Hospital progression of care and coordination of care across the continuum is already fragmented – it doesn’t need or should we tolerate further schisms.