Make the hospitalist team your new best friends
Make the hospitalist team your new best friends
Work together on documentation, patient throughput
In today's healthcare environment, as payers tighten reimbursement and auditors from Centers for Medicare & Medicaid Services and commercial payers increase their scrutiny of hospital records, hospitals need to ensure that all patients are admitted in the right level of care and that they move through the continuum as quickly and safely as possible.
Much of this responsibility falls on the case managers, and as hospitals create or expand their hospitalist staff, there's a tremendous opportunity for case managers to partner with hospitalists to improve patient care and optimize reimbursement for the hospital.
Hospitalists are more aligned with what case managers are trying to do than community physicians are because the only patients they are treating are those in the hospital, says Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources, a healthcare consulting firm in Newton Square, PA.
"There is a huge opportunity for case managers and hospitalists to work together. In many hospitals, the hospitalists are seeing the bulk of the patients and are uniquely positioned to collaborate with case managers on length of stay and medical necessity criteria," Wuebker says.
Hospitals are pouring resources into cases that are likely to be targeted by auditors. This is the perfect opportunity for case managers and hospitalists to work together to ensure that documentation is accurate and complete, he says.
Now that Medicare's Recovery Audit Contractors (RACs) and other auditors are scrutinizing physician billing, it may help build the hospitalist-case manager relationship a little quicker than in the past because the hospital and the physicians both are at risk, points out Pat Wilson, RN, BSN, MBA, case management director at Medical City Dallas.
Medical City has had a hospitalist program for more than 10 years, and over time case managers and social workers have developed a close working relationship with the hospitalist team. (For a look at how the relationship was developed, see related article, below.)
Hospitalists offer an advantage to case managers as they try to improve patient throughput and documentation because they are in the hospital all the time while physicians and surgeons make rounds once or twice a day and may not be easily reached by telephone when they are in their offices, says Linda Sallee, MS, RN, CMAC, ACM, IQCI, director for Huron Healthcare, headquartered in Chicago.
"If case managers have a good relationship with the hospitalists, they can work together to move patients along," she adds. For instance, hospitalists may have a tendency to concentrate on the new patients and their needs. Case managers may have to prompt them to write discharge orders early in the day, she says.
When case managers and hospitalists work together, it creates the best of all worlds, says Joel Botler, MD, a hospitalist at Maine Medical Center, a 500-bed medical center in Portland. At Maine Medical Center, case managers work closely with the hospitalists on determining level of care. They intervene during the course of the hospital stay to ensure that tests and procedures are completed in a timely manner and that the hospitalists are aware of the result.
The case managers and hospitalists hold interdisciplinary rounds every day along with the unit charge nurse or nurse manager and the nurse taking care of the patients. The team also includes physical therapists, occupational therapists, and pharmacy representatives when needed.
"The team discusses the elements of patient care for that day and what will happen in the future. The rounds are a key to improving patient care and throughput," Botler says.
The best model for case management and hospitalist collaboration depends on what works best at the individual hospital, Weubker says. Some hospitals assign case managers to a particular hospitalist or hospitalist team. In other hospitals, case managers are assigned by unit and may work with several different hospitalists every day.
When case managers are assigned to individual hospitalists, or a hospitalist team, they get to know the physicians and how they practice. As a result, they work closely and collaboratively and provide continuity in care to the patients, says Patricia Hines, PhD, RN, vice president of The Camden Group, a Los Angeles-based national healthcare consulting firm.
Maine Medical Center assigned two case managers to the hospitalist group when the hospitalist program began, but that arrangement became unworkable because the case managers had to go with the hospitalists to several different floors each day. Now the case managers and physicians are assigned geographically, Botler says.
Whatever hospitalist-case management model works best in your hospital, it's a good idea to assign new hospitalists to work with an individual case manager for six months or so, says Sallee, who consulted with Maine Medical Center on its hospitalist program. That way, the case managers can help the physicians learn what needs to be accomplished, such as the kind of documentation that is necessary, and the importance of writing discharge orders early in the day.
Wuebker recommends that case management directors meet with a couple of case managers and several hospitalists in small groups so each discipline can get to know each other.
"Many hospitalists simply do not understand what case managers do, but when they do understand it, they welcome the opportunity for collaboration," he says. (For more tips on working with the hospitalist team, see related article, below.)
Case managers should meet regularly with the hospitalist team during a daily huddle, a weekly team meeting or a hospitalwide meeting—whatever works best in your hospital, Hines recommends.
"When case managers and hospitalists meet regularly and work together, they have an opportunity to learn from each other and build a team esprit de corps. They can learn from each other as they delineate the roles and responsibilities of the entire team," she says.
Whenever possible, case managers should make rounds with hospitalists on a daily basis, adds Daniel Cusator, MD, MBA, vice president of physician and hospital operations for The Camden Group.
"You can't overestimate the power of having case managers round with hospitalists if it fits into the hospital work flow. It creates a collaborative team where each member understands what is going on with the other team members," he says. Rounding with hospitalists gives case managers the ability to be more proactive in discharge planning, he adds.
During rounds, case managers have the opportunity to ask the hospitalists early in the stay for information on the kind of resources patients are likely to need after discharge and for suggestions about which types of post-acute facilities can meet patient needs, says Kerry Weiner, MD, chief clinical officer at IPC The Hospitalist Company. "Physicians usually have a good idea of what facilities in the area can meet patient needs. They won't know which facilities have beds available, but they can give the case manager a starting point," he says.
At the same time, rounds give the case managers an opportunity to discuss the patient's cultural and religious beliefs, support systems, financial and cognitive issues and how they will impact the discharge plan, Weiner says.
"Many times care plans are designed for optimal situations with open-ended resources and available care givers, but it's rarely the real situation facing most patients. Physicians often don't have the time or even the experience to determine the patient's psychosocial issues, and case managers can help them create a realistic plan. If you don't have the right social situation, it doesn't matter what kind of medication regime or clinical plan you make — it won't be successful," Weiner says.
When a combination of hospitalists and private physicians see patients, it has been effective for the hospitalists to admit patients to a centralized unit, Cusator says. "The hospitalists and case managers can make rounds several times a day and make timely medical decisions," he says.
As hospitals begin to hire hospitalists or expand their hospitalist team, they have an opportunity to benchmark the hospitalists' outcomes against the outcomes of the independent medical staff, Cusator says. Assign case managers to the hospitalist team and measure the impact the team has on cost per day, length of stay, and other key indicators, he suggests. "This will allow hospitals to critically invest in the limited resources that drive improvement," he says.
Get to know hospitalists as individuals It takes patience to build a relationship The two biggest keys to a good relationship between case managers and hospitalists are to build trust and communicate constantly, says Pat Wilson, RN, BSN, MBA, case management director at Medical City Dallas Hospital, where case managers and hospitalists have worked together closely for 10 years. Building a good relationship takes patience, Wilson points out. Meet the hospitalists where they are and determine how to integrate case management and social work into the way they work on a daily basis. It's important that the hospitalist team and the case management team understand what both sides do, what their days are like, and what their challenges are, says Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources, a healthcare consulting firm in Newton Square, PA. "It's a matter of the case managers helping physicians understand what they do on a day-to-day basis and understanding how the hospitalists work," he says. Let physicians know that the case managers aren't there to criticize or make things difficult for the physicians; their role is to move the patients through the continuum, facilitate post-acute services, and help the hospital avoid losing reimbursement during payer audits, he adds. Case managers need to get to know about the physicians as individuals and understand what each one needs from the case manager, says Joel Botler, MD, hospitalist at Maine Medical Center, a 500-bed medical center in Portland. "It's crucial for the case managers and hospitalists to get to know each other. If case managers can explain how they can help the physicians on a day-to-day basis, the physicians will be eager to work with them," he says. It pays big dividends when case managers and physicians can work together as a cohesive team, Botler says. "At our hospital, it's a rarity for hospitalists to question case managers now. We depend on them tremendously," he says. Make sure you have the right people in the position initially to build the relationship. Hospitalists at Medical City Dallas told case management leadership that they wanted to work with people who had experience in medical-surgical issues, understood telemetry, and most of all were good communicators, Wilson says. Include social workers in your relationship with hospitalists, Wilson suggests. "Social workers are key at first because there's not an adversarial feeling about social workers," she says. Wilson suggests starting by working with hospitalists on unfunded patients. The hospital won't get paid for caring for these patients and neither will the hospitalists. Demonstrate that you can help move them through the continuum and that will help the hospitalists develop confidence in how case managers can help them practice more efficiently. Case managers should be proactive in seeing patients with the medical staff, whether they are hospitalists or community physicians, instead of waiting until the patient no longer meets criteria to communicate it to the physician, says Patricia Hines, PhD, RN, vice president of The Camden Group, a Los Angeles-based national healthcare consulting firm. "Case managers should begin having conversations with the attending on the day of admission," she suggests. Ask physicians what their plans are for the patient, the patient's anticipated length of stay, and discharge needs. Ask how you can assist in coordinating the delivery of care. Have ongoing face-to-face conversations with physicians. Don't wait until they have left the floor and call them on the telephone if you have questions or concerns, suggests Daniel Cusator, MD, MBA, vice president of physician and hospital operations for The Camden Group. "In the past, many case managers have not communicated with physicians until there is a denied day or another insurance issue or the patient's length of stay is excessive. This just sets the case manager up for failure when it comes to building relationships," he says. If patients are being treated by specialists as well as the hospitalist team, case managers should be the liaison between the providers and make sure all of the physicians are aware of the treatment the patients are receiving and agree on the treatment plan, says Kerry Weiner, MD, chief clinical officer, IPC The Hospitalist Company. Keep your written communication short and to the point, Weiner suggests. "Doctors don't have time to read a long note, even if it's typed. In their notes on the chart, case managers should summarize the trigger issues and put the information in bold or red for emphasis," he says. Discharge planning should begin when the decision to admit is made, and the sooner the case manager gets involved, the sooner the physician will recognize that he or she is a valuable resource to help manage care, Cusator says. Involve the executive team in facilitating the case manager-hospitalist relationship, Cusator says. The most significant barrier to creating a good case manager-hospitalist relationship is the perception that the status quo is the way things should be, he says. "People tend to want to keep things the way they have always been. That's why it's critical to have a clear vision of the process that is articulated by whoever is the leader of the initiative, whether it's the chief executive officer, the chief medical officer, or the chief nursing officer," he adds. In some hospitals, the executive management team may send mixed messages about the role and function of the case management team, Hines says. "In some respects, the case managers' role augments that role of the staff nurses because they are coordinating care throughout the stay and the staff nurse is focused on what happens during a shift," she says. Hines recommends that hospitalist orientation include education about the role of the case managers and social workers along with the mission and values of the hospital. "Case managers need to teach the hospitalists that their goal is to ensure that patients get the right care at the right time and in the right place. When both get together and communicate, it can be a very successful partnership," she says. |
CM-hospitalist relationship took time Efforts started with education When Medical City Dallas Hospital began its hospitalist program more than 10 years ago, the hospitalists' average length of stay was within two days of the geometric mean length of stay. Now it's within a half a day. "This is a significant reduction in length of stay, but it didn't happen overnight. Our hospitalist-case manager relationship has evolved over the years, and it continues to evolve based on the needs of the hospital and the patients and the role of the case managers," says Pat Wilson, RN, BSN, MBA, case management director. Hospitalists at Medical City Dallas see the bulk of the medical patients. Before the hospitalist program started, the hospital's case management leadership worked closely with the director of the hospitalist program to find out the hospitalist team's understanding of the roles of case managers and social workers and their expectations for working as a team. "We found out that the hospitalists perceive social workers as a good thing, but we found that we had to do a lot of education about case managers, their role, and how they can help the hospitalist team," she says. The case management team started the educational processing by saying that the case manager is the clinical liaison between the patient, the family, the insurance company, and the physician, and that the case manager can translate the physician's plan of care to the family, the patient, and the insurance company, she says. "We emphasized that the case managers are concerned with anything that affects transition in care and can facilitate the physician's orders," she says. For instance, the case management team explained that if a physician is waiting on the results of an MRI to discharge the patient, and the case manager finds it has been delayed, he or she will call radiology to find out what's happening and notify the physician, lightening their load. On the other hand, if a lab draw or another procedure wouldn't help move the patient to the next level of care, the case manager will concentrate on something else, like facilitating the orders for discharge, she says. The team asked the hospitalists what kind of person they want to work with and how case managers could meet their needs. "They started opening up and said they wanted to work with someone who has expertise in caring for med/surg patients, who knows telemetry, and who is a good communicator," she says. The case management leaders used the information they got from the hospitalists to choose the right social worker and the right case manager to work with the hospitalist team in the beginning. At first, the case management department assigned a carefully selected case manager and a social worker to work with the hospitalist team and build a good relationship. "In the beginning the social worker was the point person with the hospitalists because she knew the cases from a social perspective and could facilitate discharge plans for patients who were unfunded or had other discharge needs. As time went on, the hospitalists learned to trust the case managers and to understand that when we look at medical necessity, we're not telling them how to practice medicine but are helping expedite their orders," Wilson says. About two years later, the role of working with the hospitalists shifted to the unit-based case managers and social workers. "Once the case manager and social worker assigned to the hospitalist team proved their value to the physicians, it was easy to translate that relationship to any case manager or social worker," she says. In addition to working with them on the unit, the case managers and social workers met with the hospitalist team weekly to talk about patient needs, barriers to discharge, and to share information on patient delays. Before the weekly meetings, the social worker and case managers reviewed the patients on the unit and brought up the unfunded patients and those with complex medical or social needs and issuance issues for discussion. "The weekly conferences were a good way for the hospitalists to get to know the case managers and social workers they would be working with. They'd seen them on the unit and worked with them occasionally but hadn't worked closely with them," she says. Once the hospitalists developed the same kind of trusting relationship with all of the case managers and social workers, the case management team moved to quick daily huddles between the hospitalists, the case managers and social workers on the unit. During the meetings, they look at every unfunded patient. The case manager talks about the clinical length of stay and the plan of care. The social workers identify barriers to the plan of care. When appropriate the team pulls in physical therapy or other ancillary services to the meeting. If the hospitalists are admitting patients through the emergency department and recognize that the patient has complex social or clinical issues, they often contact the case manager or the social worker on the unit to which the patient is being admitted and alert them ahead of time that the patient is coming in. "There's constant communication between the case managers, the social workers, and the hospitalists," Wilson says. For instance, if a patient is waiting for post-acute placement, the social worker keeps the hospitalist informed when a bed is available. The case managers alert the hospitalists if there are insurance issues. "Our hospitalists truly understand medical necessity because from the beginning, we talked about the role and we continually provide education on the subject. They understand that we apply InterQual criteria and that when patients don't really need to be in the hospital, it's poor utilization of resources whether it's the hospital's or the physician's. We have truly developed a good relationship that benefits the patients, the clinical team, and the hospital," she says. Sources
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