Managing Staff Shortages and Improving Collaboration in Case Management
As the issue of staffing needs in the case management world — and the medical field at large — continues, many systems are considering how they can make the most of a difficult situation. While those problems seem to be multiplying during what many are calling “The Great Resignation” or “The Great Resettlement,” leaders like Therese Fitzpatrick, PhD, RN, FAAN, and Brian Pisarsky, RN, MHA, ACM, both senior vice presidents at Kaufman Hall, are addressing the issues strategically.
“Our focus is looking at the whole organization,” Fitzpatrick says. “While we may have significant focus on nursing today, it’s all of the departments working together.”
Going into the COVID-19 pandemic, there was “already a [staffing] shortage, so now the pipeline is constrained,” she adds. “We turned away almost 90,000 well-qualified nursing student candidates because of a shortage of clinical sites. We’re facing the retirement of baby boomer nurses and bearing down on years of significant retirement. We were hit hard.”
Fitzpatrick also notes students could not get into the hospitals to complete their rotations, and many needed to finish their clinicals in simulation settings. “This, coupled with folks being burned out, the increased violence in workplaces, and people leaving organizations to instead do travel contracts, has meant a trying time — pretty unprecedented.”
According to a recent report from Kaufman Hall, “During the pandemic, almost one in five healthcare workers quit their jobs. One-third of nurses plan to leave their current roles by the end of 2022, with more than a quarter of those intending to become traveling nurses. At the same time, hospitals find themselves competing with non-hospital employers that are aggressively pursuing hourly staff — companies that can pass along wage increases to consumers in the form of higher prices in a way that healthcare organizations cannot.”1
Without appropriate staffing, “the length of stay goes up and throughput is diminished,” Pisarsky says. “It’s harder to get patients into nursing homes, for nurses to care for patients at home with home healthcare, and it’s all impacting the length of stay in the hospital. There’s a need for more nurses to care for those with [long] length of stay and census.”
Likewise, nursing homes and long-term care facilities are experiencing these problems exponentially.
Mitigating Issues Through Staffing
To help make the best of the situation, Pisarsky says organizations should work to adopt a “triad model” — pulling out utilization review, case managers, and social workers to work collaboratively.
This frees the social worker to focus on “difficult psychosocial issues” while the case manager “can look at medical necessity and the throughput side of it, getting the assessment done within the first 12 hours and beginning to plan discharge from the moment of admission,” Pisarsky adds.
With this model, the effects of one temporary absence are not as great. If the three people in the triad can collaborate well together, it is an ideal situation in the best of times, and less stressful when staffing levels are low.
Receiving the benefits of this appropriate staffing is in essence why patients come to the hospital at all. “I was with a system CEO/physician, and he said it so articulately: ‘Patients are in the hospital to receive nursing care,’” Fitzpatrick says. “It’s true. Patients are literally there to receive high-level, vigilant 24/7 care. It’s critical. If we don’t have the appropriate level of care, then we have to make hard decisions about diverting care from hospitals. We need to be here for our communities, and if we have to divert or delay procedures, whether elective or semi-elective, that’s not a place we want to be.”
Fitzpatrick’s concerns for quality care in the community also extend to healthcare workers — and even hospital systems. “Not only do members of the community need access to care, but they need safe care within organizations,” she notes. “Safe care is not just for patients, but for care teams as well. It’s crucial to have the right numbers and the right configuration of staff at the right cost. Staffing shortages are significantly impacting expense and revenues of organizations, too.”
The Kaufman Hall report authors noted these key findings on the financial effect of workforce shortages:
- Hospital labor expenses increased by more than one-third from pre-pandemic levels;
- The West and Northeast/Mid-Atlantic expense levels were consistently the highest, while the largest increases occurred in the South and West;
- Contract labor increased more than five times the rate from pre-pandemic levels;
- The median wage for contract nurses is three times that of employed nurses;
- Dramatic declines in year-to-date operating margin.
“The goal is to provide the right care at the right time and in the right setting,” Pisarsky said. “We have to move patients through because, for example, if the patient is 85 years old and spending a night or two in the ED, that’s not the right setting for them. Inpatient care is not meant for the ED, and it’s harder to have interactions that we’d normally have with families in that situation.”
Staffing Based on Needs
One way to help is to adjust staff in acute care consistent with needs.
“We have to have the ability to flex staff according to demand,” Fitzpatrick says. “We are seeing creative things happening around float pools as well. Some hospital systems across multiple states have developed the ability to create private-label staffing companies, and others have been able to move staff according to demand and across states as well.”
Regarding case management departments, Pisarsky notes “agencies have been increasingly working to fill remote utilization review or case management roles. Five years ago, you’d hear of that happening only rarely or just on an interim basis. Now, we get frontline staff from agencies to help hospitals fill roles as needed. The cost is higher, but the nice thing is that most of the time, the staff is very experienced, has worked in multiple hospitals, and can plug and play in any place they land.”
The Importance of Collaboration
As all the staff endures the effects of shortages, appropriate collaboration becomes clearer and more significant. Nurses and case managers must work together to ensure everyone in the hospital is there because they genuinely need to be there. Extra work must be undertaken to ensure each patient’s plan is effective and on-track.
“What we’re finding across the country is that, whereas case management and nursing each stayed in their lanes previously, they now have to work across lines and understand what the other is doing,” Pisarsky explains. “Multidisciplinary rounds in all units are essential. Safety huddles in the morning help staff collaborate on what’s going on in the hospital and discuss how to move patients through the system in the right way and as safely as possible.”
Both Fitzpatrick and Pisarsky acknowledge case management should ensure the right people are present during collaboration sessions, including physicians, physical therapists, oncology teams, or whomever is appropriate for a particular patient. For the sake of accountability and excellent communication, case management also should work to find creative ways to include the patient and their family as often as possible, especially when discharge plans are discussed.
“We all need to be thinking, ‘How can we do this together and be more in sync with peers?’” Pisarsky says. “Sometimes, we forget that. But if we function as a nimble organization and creatively think outside of the box, we’ll win. We need to keep in mind what is best for the patient, then communicate that plan with each other, the plan for today, the rest of the stay, and any barriers to that throughput and plan.”
Some of this creative thinking comes down to quick problem-solving, Pisarsky notes. For example, if MRI machines are down, instead of accepting the delay it might cause, the team can consider where else an MRI can be performed. If the physical therapy team is overwhelmed or short-staffed, nursing might ambulate the patient instead.
“This kind of collegial work together is really helpful,” Pisarsky says. “Some organizations are doing it well. They are having those discussions all day, every day. They’re working together to meet those goals and successfully evaluate patients for discharge in order to empty out the ED and avoid having to cancel surgeries.”
After all, “it is all about the patient and providing for them the best care — the care that they deserve and need,” he says. “They are putting their lives in our hands, so we need to keep them center and foremost. That way, the patient wins every time, and that’s what we want — for them to get the services and care that they need.”