Making the case for a new hospital case management model

by Stefani Daniels, Founder and Managing Partner
Published on Feb 08, 2018

Uncertainty is a word used in every conversation around healthcare these days: uncertainty about reimbursement, technology, and patient care delivery. The discussions around the transition from fee-for-service to accountable care organizations, population health and pay-for-value models, make capital investments a very risky business. But investment in a new case management model is a low cost, high value bet on the future of care coordination.

It started out as an innovative nursing care model in the early 1980s; after the DRG fiscal meltdown, it veered off-track to a discharge planning/utilization review model incorporating several peripheral/add-on activities; then it shifted to an emphasis on achieving outcomes following the publication of To Err is Human; and now, after 30 years, hospital case management is shedding its extraneous baggage to concentrate on its primary founding activity: care coordination.

It took 30 years to go full circle, but the preparations for a value-based healthcare environment has opened the eyes of many hospital leaders who finally recognize the essential value of a care coordination approach to manage selected patients across the continuum. Irrespective of the congressional debate about the ACA, significant reform of the care delivery and payment systems is on its way. While the specifics may still lack clarity and the implementation timetable may be uneven, the agenda for change is happening and hospital leaders will sooner – rather than later – begin their repositioning initiatives because the new marketplace requires a fundamental redefinition of the hospital-success model.  

One of those initiatives has turned the spotlight on the hospital’s case management department. As they ponder to determine how the hospital can be successful in the future, the executive team is addressing the concerns that have surfaced during the move to value-based care. And many of those concerns relate to coordinating care for selected patient populations across the continuum. Execs and hospital case management leaders are quickly realizing that traditional case management assumptions are outdated and a new value-based approach is essential to thrive in new marketplace. 

Care coordination has always been considered a component of case management but other than 'coordinating' the patient's discharge plan, it gets short shrift. Many hospital case management departments are so overburdened with tasks to be completed, that any thought of coordinating care for selected vulnerable patients has been lost or delegated to ACO or payer representatives. Over the years, more and more tasks were added to the case manager role until care coordination, while always on the minds of many thoughtful case managers, took a back seat to planning and arranging discharges, reviewing charts for utilization review, and scores of chores that surfaced to meet hospital, regulatory or medical staff needs (see previous blog post Role expectations became overwhelming and demands for 7 day utilization review and discharge planning services led to quality of life challenges, frequent absences and vacancies, fragmented services, and difficulties recruiting replacements willing to take on such an overburdened role.   

In addition, there are not many hospital case management leaders nor their executive sponsors who fully understand WHAT care coordination really means and are less familiar with the explanations offered by AHRQ or NQF which cite that care coordination is a deliberate, longitudinal and pro-active process of sharing information among all providers to "avoid waste, over-. under-, or misuse of prescribed medications and conflicting plans of care" to achieve safer and more effective care outcomes. This lack of insight about the intent of care coordination, translates into hospital case management departments that are still focused on discharge planning, staffing ratios, dyad and triad models, productivity measures, and other topics focused on how to do discharge planning and utilization review better, rather than transforming into hospital wide programs to effectively coordinate the care of the most vulnerable populations.  

Visionary leadership helps turn a good organization into a great organization. Executive suite leadership sets the culture, tone and expectations of quality, safety and cost effectiveness but it is the case management leader who must rethink the future and is the individual most influential in transforming a legacy task-oriented case management department into a hospital wide care coordination program.  It is a daunting responsibility with many moving parts involving the medical staff, business operations, and patient care. This is not the time for a passive posture to reinforce comfortable, familiar ways of operating and it is not the time to dig your heels in to maintain the status quo.  Rather this is a prime leadership opportunity to explore new horizons, and respond effectively to changes in the marketplace that require a new strategy and new goals and to give dynamic meaning to the work we are supposed to do as case managers.

Note that I emphasize the difference between department and program.....Care coordination is not a department. It is, or should be, a core competency of the organization involving every care team member and business associate. Leadership must make sure every hospital associate understands the vision of care coordination and what role they play in achieving it. Care coordination is an enterprise-wide program and every employee knows what they need to do to bring the vision of care coordination to life in the hospital and in the community.   

It means setting audacious goals and enlisting colleagues and champions to help achieve them.  It means restructuring and reorienting the resources hidden in various service lines and deploying them more effectively across the continuum.  It means evaluating all non-value activities currently assigned to the case management "department' and finding the right home for them.  And it means that everyone is responsible to call out barriers and problems to efficient progression of care, to question the purpose of low-value medical interventions, and to experiment with options that will promote and hardwire teamwork.  

Care is being delivered in more settings than ever before.  The walls of your hospital no longer define the limits of care coordination responsibilities. Hospital leaders are cautiously experimenting with risk-based payments extending beyond hospital boundaries and hospitalists are doing the same with greater emphasis on multidisciplinary teamwork while exploring the benefits of regionalized care. Multidisciplinary care teams are widely regarded as the most effective structure for improving care for defined populations. I have seen a variety of approaches to care teams, some with fewer staff and some with more.  And when fewer are involved, coordination often suffered. I have found that all care experts are needed at the table to efficiently address the many questions and concerns that surface at team meetings. High quality care coordination is built on a collaborative, multidisciplinary, and highly communicative care team working on behalf of the patient and family which, in addition to greater hospitalist efficiency, seems to be the motivating force behind accountable care units.  

At a time when hospital leaders are carefully reviewing all aspects of operations to determine ways to reduce costs and increase efficiency, care coordination activities play an important role in managing resource utilization and costs per patient day. And while many CFOs are still slavishly focused on length of stay, unless there is a capacity issue with patients waiting for beds with diagnoses that will result in revenue that exceeds the negative margin stemming from excessive costs, greater focus on resource utilization must be given priority.  By working closely with high-risk patients and their families, along with the physician and the care team, case managers play a critical role in ensuring that patients received the right care, at the right time in the right setting. They are best positioned to encourage the use of evidence-based guidelines, to promote concise documentation at the point of care, to influence seamless transitions and to question the use of wasteful, excessive or potentially harmful interventions. More than ever, hospital case managers must be assertive advocates to keep safety, quality and cost efficient care on the minds of each member of the care team.