Who should own case management within the continuum of care?
Who should own case management within the continuum of care?
Everyone, say advocates for interdisciplinary approach
As greater emphasis is placed on managing patients throughout the continuum, case managers increasingly may find themselves in a tug of war with pre- and post-acute care colleagues over who should "own" case management. Where, many ask, should ultimate responsibility for case management lie?
Hospital Case Management editors posed that question to several experts and found that they are not interested in the consolidation of case management. Instead, they argue for an interdisciplinary approach that handles each patient individually.
"There’s no need for centralized case management," says private consultant and author Elaine L. Cohen, EdD, RN, a former vice president of patient care at Dakota Heartland Health Systems in Fargo, ND. "What’s important is that case managers at different levels home care and acute care, for example are able to take an interdisciplinary approach in support of the patient, cooperating with each other toward a common outcome."
Nursing’s project becomes nursing’s problem
Problems inevitably arise when any one entity is responsible for coordinating the care of a patient population, adds Sherry Lee, RN, BSN, MEd, an informatics and case management consultant based in Charlotte, NC. "If nursing takes ownership, then you tend to have everyone sitting back saying, this is nursing’s project, and if it fails, it’s nursing’s problem. If it’s social work’s project, then the same thing tends to happen. I think everyone puts in more of their own effort if it’s a joint interdisciplinary project, so that it’s not owned by any one discipline in the hospital, but across the continuum of care."
Indeed, traditional case management, essentially involving nurses managing patients by telephone, is "highly outdated," argues Rosario J. Lopez, MD, medical director for western operations and senior vice president for medical affairs at Birmingham, AL-based MedPartners, which owns a number of hospitals and medical centers. "Now, the real people who are doing the work are multidisciplinary teams," he says.
Lopez stresses that, although a lot has been said about coordinating care across the continuum, less attention has been paid to the need for continuity in the inpatient setting. "It’s even more critical there," he says. "Making sure that there is a physician continuously available to take care of patients in the hospital, coordinating services, coordinating specialty care and consultations, and being available to patients, their families, and other professionals is extremely important, and it requires a multidisciplinary approach."
Inpatients and outpatients benefit
Administrators at MedPartners hospitals have found that interdisciplinary approaches benefit patients by fostering a greater level of interaction among those providing care. "We think that leads to better outcomes and shorter lengths of stay, and thus more cost-effective care with higher quality," says Lopez. "On the outpatient side, it leads to better coordination of care: patients going to the right place at the right time, instead of being lost in a maze and being bounced from one inappropriate specialist to another."
What’s most important to remember, say advocates of the interdisciplinary approach, is that where case management occurs is less important than the fact that the care is being coordinated by somebody. The decision of who should assume central responsibility for managing a particular case should be made not on the basis of some externally imposed chain of command, but rather should be governed by the specific needs of the patient.
"Certainly there needs to be somebody who helps to assure that patients get from one place in the system to another, and that they get the right care at the right time in the right setting," says Lynn Brofman, RN, MSN, vice president of clinical operations for Interim HealthCare, a national home care company based in Ft. Lauderdale, FL. "In order to do that really well, the overall program needs to be planned with all of the players at the table."
"If case management should be centered anywhere, it should be centered with the patient," asserts Cohen. For example, one patient with COPD, a chronic lung disease, is in control of her condition and is rarely admitted for acute care. In that instance, it makes more sense for the patient’s care to be managed via home health. Another, less controlled COPD patient, who is frequently in and out of an acute care facility, is perhaps best managed by providers at that facility. "Or, in some instances, since home health is vitally important to certain patients, perhaps it should be a joint leadership role between acute care and home health," says Lee.
Home care manages disease well
Brofman believes home care is capable of playing a more active role in the case management of patients across the continuum. "I don’t hear a lot about how people envision the role of home care, so I would like to see more recognition of what home care can do, particularly in the management of disease. Many of these patients, because of the chronic nature of their condition, are seen over long periods of time by the home care agency," she says.
Providers at the Cooley-Dickinson Hospital (CDH) Inpatient Psychiatric Unit in Northampton, MA, hit upon a novel way to smooth the coordination of inpatient and outpatient case management, says David Powers, patient care coordinator at CDH. As part of a pilot project, CDH allowed length of stay for psychiatric patients to increase slightly. That allowed outpatient case managers to meet and connect with patients prior to discharge. The hospital also worked with outpatient case managers to coordinate appointments, make home visits, and otherwise assist the patient in easing the transition from inpatient to outpatient status.
At MedPartners-owned hospitals, including those in the Friendly Hills Network, the Mullican Organization, and U.S. Family Care, interdisciplinary teams meet daily to discuss the care of each patient in the hospital. "You have the whole team sitting at the table dietitians, social workers, nurses, respiratory therapists, pharmacists, everyone," says Lopez. "All of them meet to learn what they need to know about a given patient, and everyone gets a chance to give their input as to what may help the patient get better."
For example, a social worker might mention that a particular patient is malnourished, and that perhaps the dietitian should perform an assessment to determine a course of action. Or, a nurse or respiratory therapist might contend that the settings on a patient’s respirator are inappropriate and recommend a change. "This type of opportunity [for discussion] is critical if the patient is really going to get comprehensive care," says Lopez.
Put everyone at the same table
Making sure case management truly is an interdisciplinary process, however, is easier said than done, maintains Brofman. "We always say we want to work as a team, but the actual logistics of doing that are sometimes very difficult," she says. "If we really are going to be successful, we will sit down together and agree that this is your role, this is my role, and this is what each of us is going to contribute."
For example, case managers at Interim conduct pre-op visits with patients scheduled for cardiac surgery. "We coordinate the content of that visit [with providers] so that a lot of the things we discuss can be in conjunction with what the patient’s going to experience when he or she gets to the hospital," says Brofman.
The key is to make "interdisciplinary" more than merely a buzzword. Weave cooperation into the fabric of your program from the start, experts say. "I stress very strongly, from the get-go, that it is an interdisciplinary project and never owned by one discipline," says Lee. "If you bring in social work, utilization review, nursing, and others, and help them all start to learn to work together, it can happen. That’s just plain old good continuity of care."
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