Here We Go Again

by Stefani Daniels, RN, MSNA, CMAC, ACM
Published on May 31, 2015

That was one case manager's reaction when she learned that the case management department would be reorganizing itself to move to an 'outcome-oriented' practice model.

Here We Go Again article imageOver the years, case managers' mettle has been repeatedly tested as new-and-improved approaches to case management emerge, only to eventually fade into oblivion as case managers return to the comfort of discharge planning and utilization review activities. The skepticism is laced with suspicion that redesign is little more than a guise for reducing staff and replacing them with less skilled and less expensive workers.

Nevertheless, case management redesign is more than just a fad….it’s a reality. Very real and profound changes in the hospital marketplace are forcing hospitals to take a hard look at how they are using valuable case management resources. Many have decided that to survive in a more competitive environment, they have to become more responsive to customer's needs and insurers' cost-control pressures. To survive, hospitals have had to confront the reality of regulatory oversight, physician relationships, revenue shortfalls, and customer satisfaction.

Over the past 3 years, execs have dissected and examined the whole structure of case management services and have come up with some intriguing findings:

  • Little of the case managers' time is spent with patients and physicians. More time is spent phoning, faxing, reviewing, and documenting.
  • There are too many system barriers to effective progression-of-care. These include bureaucratic barriers - time to make a decision, and process barriers - the delays in providing prescribed services or treatments.
  • Rather than expediting care, the organization of services into self-contained silos actually impedes care and discourages the professional relationships necessary to deliver it effectively.
  • Integration and coordination of care is thwarted by the professional ownership model. Each discipline claims 'pieces' of the patient without putting the pieces back together to construct the whole person.
  • Many services and activities provided by highly educated individuals can be performed by less trained personnel without sacrificing quality care.
  • Physicians aren't engaged into the care process in a way that ensures effective alignment with colleagues in other disciplines or the hospital.

Redesign begins from these observations. It's based on the recognition that hospital care may not be organized as it should be to use resources effectively and best meet the needs of the patients. It calls for a radical change about how hospital case management is practiced. Are you ready?