The Hospital Care Manager

by Stefani Daniels, MSNA, RN, ACM, CCMA
Published on Jul 05, 2016

With a contemporary approach to hospital care management, patients are prioritized based on risk and opportunity for care management. The patient might have chronic illnesses, multiple admissions and readmissions, frequent visits to the ED, certain diagnoses like depression, polypharmacy or psychosocial challenges that interfere with the patients' ability to maintain health.

For over 20 years I have been advocating for the practice of case management as it was originally intended.  If you read the literature of the late 1980s, early 1990s, you will understand, as I did, that case management was adopted in the acute care setting to facilitate the patient’s progression of care when the prospective payment system was introduced.  By designating the admitting nurse as the nurse case manager, the patient’s acute episode of care was under the oversight of the nurse case manager wherever the patient was cared for in the hospital setting.  The original goal – in keeping with the false assumption that lower length of stay equated to lower resource  costs  (see The Myth of Length of Stay) – was to lower LOS by expediting care, preventing duplicative interventions  (if it was done in the ICU why does it need to be repeated on the medical unit?), and influence a timely transition.

It was only when the management engineers were called into the hospitals by frantic execs who were floundering under the DRG payment model, that we saw the integration of the UR depts. and the SW depts to create case management departments --- but, and this is important reminder ---- the practice of case management as intended was lost.

The publication of To Err is Human in 1999 coupled with the DRA of 2003 (which foretold of the RACs and MACs) and the MMA of 2005 which announced P4R,  the precursor of VBP, prompted a focus on outcomes and with it came the redesign of the case management programs in many hospitals…from completing the tasks associated with DCP and UR, to generating objective improvement in clinical and financial outcomes.  Around the same time we saw the Feds growing weary of the failure of the PSROs to monitor medical necessity and they restructured the whole process under a PRO program which eventually turned into the QIOs. 

It was a combination of these marketplace challenges that told those of us in the C-suite at the time that we better do something to more effectively monitor and manage patient care.  And that’s when I knew that the functional model of case mgt just wouldn’t work and reading Zander’s experiences at New England Medical Center, convinced me that case managers must be positioned to work in tandem with the patient’s physician and care team to safely, effectively, and efficiently manage progression of care.

The demands to ensure medical necessary have not gotten less easier over time either.  Indeed, they have escalated significantly.  For a hospital exec or a case management program leader to consider the expertise needed by a UR specialist as being an ‘add-on’ to the coordinating role of the care manager is, in my opinion, wrongheaded and hindsighted.

Hospitals must determine and are held accountable to make sure that patients accessing acute care services require acute care services and the rules and regulations governing those requirements are staggering  (See my latest publication, The Hospital Guide to Contemporary Utilization Review).   At the same time, the risks associated with hospitalization have increased dramatically so that many patients truly need a real time advocate to prevent excessive, wasteful, duplicative, or potentially harmful medical interventions. And because advocacy is the hospital care managers’ primary ethical obligation, how better to exercise that obligation  than to be partnered with the physician and to have real time conversations with him/her and the clinical team to try to influence the patient’s treatment plan, delivery of care processes, progression of care goals, and transition planning.

Chart review, in my opinion, is never the case manager’s primary source of information – ever.  (Its why doctors still speak of the ‘chart police’ when they really mean their professional case management colleagues). I expect the case manager to speak to the nurses, round with the doctors, visit with the patient and family, reach out to the therapists, pharmacists, and other members of the patient’s care team and, when necessary, advocate on their patient’s behalf with the insurer.

With the evolving marketplace changes, hospital care managers practicing in a contemporary case management environment are well positioned to extend case management principles beyond the walls of the hospital.  Which is why I am now seeing (and reading about) the introduction of predictive analytics and population health concepts being applied  to carefully selected inpatients for care management oversight in the hospital and into the community as part of innovative transitional care mgt programs. Unless hospital case managers see themselves as true advocates to coordinate care for their patients, I’m afraid (and I see some evidence already) that they will loose out on future opportunities.  

The question remains – which model is best for your hospital.  And the best answer I can give you is to first ask what is the purpose of YOUR case management program.  And to get that answer you MUST poll the C-suite.  If they just want  UR and DCP then you really don’t need case management.  Bite the bullet, sunset case management, and return to separate functions.  But if the Board and the C-suite are looking to case management to improve quality and safety outcomes of care; reduce resource utilization and lower costs per case; promote the use of evidence based protocols; identify and resolve delivery of care bottlenecks that delay or impede the patients progression of care; and engage the medical staff as colleagues in the mission of the organization, then I suspect you want to go back to the future and consider contemporary, 3rd generation care management models.