Kathleen A. Bower, DNSc, RN, FAAN

Managing Care: The Crucial NursingCaseManagement Partnership

December 201226 Nurse Leader

Readmissions, throughput, capacity,Hospital Consumer Assessment ofHealthcare Providers and Systems (HCAHPS) scores

laser-like focal points for every hospital. Enter Recovery

Audit Contractor (RAC), Medicare Administrative

Contractors (MAC), Comprehensive Error Rate Testing

(CERT), Medicare Integrity Program (MIP), and other

auditing entities, and the incentives grow larger while

the penalties become more draconian. Medicares

Recovery Audit Contractor program provides an exam-

ple. It retracted $828.3 million from acute care hospi-

tals in California, Florida, and New York during a 3-year

demonstration program.1 It has since expanded to

include all hospitals and states.

www.nurseleader.com Nurse Leader 27

In this environment, the emphasis within healthcareorganizations must simultaneously be on clinical, satis-faction, financial, and compliance goalsgoals that cannotbe achieved in isolation. Two major roles in reaching thosegoals are case management and nursing. A strong partner-ship between them is more imperative than ever before. Inmany organizations, case management reports to the nurseexecutive. Whether this is the case or not, nurse leadersplay a major role in case managements success and increating that strong partnership. This article focuses onclarifying case managements role within todays healthcareorganizations and on exploring strategies to increase theeffectiveness of the partnership.

CASE MANAGEMENT IN TODAYSENVIRONMENTCase management is the only role in healthcare organiza-tions that simultaneously and operationally focuses on clini-cal and financial outcomes. This reflects case managementsoverall goal of managing individuals at their maximumlevel of comfort, functionality, and independence while atthe lowest and most appropriate level of intensity of serv-ice. Case management works within the arenas of coordi-nation of care, utilization management, and dischargeplanning/transition management. Nurses and social work-ers in case management bring highly specialized knowl-edge, skills, and processes to their work.

Because nurses and social workers in case managementhave expert clinical knowledge and skills, they work toensure that patients receive the most appropriate care, in themost appropriate location, and with the most appropriatefinancial outcome for the patient and the hospital. They dothis through attention to care coordination. Without this,there will be ineffective utilization management and reactivedischarge planning.The ability to coordinate care requires theclinical knowledge that both nurses and social workers bringto the case management practice.

In most hospitals, Medicare is the highest volume payer,and in this highly regulated healthcare environment, casemanagement staff are the only internal experts regardingMedicares Conditions of Participation and its require-ments regarding utilization management2 and dischargeplanning.3 Case management staff operationalize thoserequirements through the implementation of:

Patient/family choice regulations Medical necessity Level of care designation (in patient or outpatient

observation) Hospital Issued Notices of Non-Coverage (HINNs) Condition Code 44It is important for all staff to know that these processes

are mandated by federal regulations and are directly linkedto payment and penalties. For example, if a patient is trans-ferred to a skilled nursing facility and it is discovered thatthe patient did not meet medical necessity criteria forinpatient level of care, both the sending and receivingfacilities are penalized.

Case management also works to ensure that every stayand every day is medically necessaryand paid.Operationally, case management staff function as complianceand payer contract managers at the patient interface. Thosefunctions ensure that patients receive the benefits in theirpayer contracts and reduce their financial burden of illness.Simultaneously, case management staff set the stage for thehospital to receive the most appropriate reimbursement,reduce denials, and mitigate external audit risks.

Alert to signs of patient readiness for discharge, case man-agement staff collaborate with the healthcare team to main-tain progression along the expected trajectory.With theirknowledge about community resources and how to accessthem, they expedite transitions at the most ideal time. Theyprovide education to patients/families about those resources,the costs associated with them, and what their insurance islikely to cover. Case management staff, particularly socialworkers, support decision making and the ability to absorblife-changing news about their health status.These interven-tions support patient/family satisfaction with the dischargeprocess, management of length of stay, compliant discharge tothe most appropriate level of care, reduction in the numberof long-stay patients, and improved capacity and throughputmanagement.

Case management has always been important to an orga-nizations successtoday it is critical. Success depends largelyon a department director with deep and current knowledgeof the many regulations within which case managementworks. Staff must be expert clinicians, have current knowl-edge about each segment of their roles, and be skilled inareas such as negotiation and communication.Appropriatestaffing is needed to achieve outcomes, including all careareas and points of entry (such as the emergency departmentand access), weekends, and replacement for staff time off.Effective networking by case management with key partnersis essential; those partners include, but are definitely notlimited to, finance, compliance, revenue cycle, access, phar-macy, and therapies. One of the most important partnershipsis the one with nursing.

THE PARTNERSHIP WITH NURSINGNursing plays a critically important role in patient care man-agement and reaching organizational goals. Nursing staffmake many contributions to those goals and to effectivemanagement of patient care, including:

Knowledge of the patient/family, including their goals,diagnoses, usual trajectories, expected outcomes, andanticipated discharge date

Comprehensive and ongoing assessments of thepatient/familys current status

Intervening when patients are not progressing as anticipated

Attention to and management of basics such as painmanagement, activity, skin integrity, bowel and bladder,and cognition

Education of patients and families, particularly in preparation for discharge and to reduce readmissions

December 201228 Nurse Leader

Identifying barriers to discharge and intervening toovercome them

Communication of the patient/familys current plan,status, needs, issues, and concerns to other shifts andother members of the interdisciplinary team

In addition to their clinical depth, nurses need knowledgeabout financial aspects of care. Examples includepatient/family financial obligations, how hospitals are paid andunder what circumstances, with a particular focus onMedicare beneficiaries. Many nurses do not have realisticinformation about Medicarefor the patient or the hospi-taland believe that hospitalization does not require paymentby beneficiaries. Many also believe that Medicare benefits areunlimited.Those beliefs are not accurate. The booklet, Medicareand You,4 produced and updated each year by the Centers forMedicare and Medicaid, should be required reading for everynurse. Management of length of stay for every patientbecomes essential for clinical reasons (e.g., reducing the inci-

dence of hospital-acquired problems) but also to reduce thefinancial burden of illness for patients/families and to ensurereimbursement for the hospital.

Empowering staff with this knowledge helps them under-stand the need to aggressively manage length of stay.Theythen better appreciate the need not to advocate for onemore day unless it is medically necessary. It also gives themawareness that case managers are required to administerHINNs to transition financial responsibility to Medicarepatients when they no longer meet criteria for inpatientmedical necessity.

Nurse leaders knowledge of the role that case manage-ment plays and their advocacy for it are absolutely necessary.The nurse leaders in the partnership assist in establishing aninfrastructure to develop and maintain close collaborationwith case management.This includes:

Actively focusing on patient care management with staff Purposefully partnering with case management staff

Figure 1. Unit Based Care Management Inventory

Assess your unit/area, indicating your level of agreement with each statement below. Then total your scores in the area provided.4 3 2 1

Yes, Rarely/Absolutely Usually Sometimes Never

Intershift report consistently provides information about the plan for each patient.Intershift report includes an anticipated discharge date for each patient.Discharge planning rounds are held on my unit(s) a minimum of three (3) times per week.Discharge planning rounds identify discharge needs, potential barriers, and next steps for each patient.Staff nurses present information related to discharge needs about their patients... beyond that usuallypresented intershift report.Patient focused team meetings are held for patients who are significantly varying from the anticipated lengthof stay and/or who are likely to experience an excessively long stay.If a patient is readmitted, a thorough assessment of potential causes is undertaken as a foundation topreventing future readmissions.Special attention is paid to the discharge plans for patients who are readmitted.There is a structured review process undertaken for each patient to is hospitalized for seven days or more(excluding neonates and psychiatry patients for whom the trigger length of stay may be longer) to identifyaggressive plans for moving the patient towards discharge.Patients who are identified to be at risk are immediately referred to the appropriate service for intervention(ex., Social Work, Case Management, Nutrition, etc).There is an identified RN who provides or oversees the care of each patient on my unit for each shift.RNs on my unit(s) are assigned the same patients when they are scheduled to work sequential days.There is continuity of nurse provider for the patients on my unit(s), either a Patient Care Coordinator or chargenurse.The RNs on my unit(s) can articulate the goals of care for each of their patients.Initial assessments identify patients at risk for clinical complications and/or extended lengths of stay.The plan of care or Clinical Path/CareMap provides sufficient information for the staff to step into thepatients care with adequate knowledge of the patients current status and plan for the day.The nurses would say there is excellent communication with physicians about patient status and plans for care.The physicians would say there is excellent communication on my unit with physicians about patient status andplans for care.Totals

1. What are your units areas of strength?

2. What areas need to be improved?

3. What are the most important areas needing improvement.

4. What should your next steps be to address areas identified as needing improvement?

2012 The Center for Case Management. Used with Permission.

Collaborating to achieve mutual patient caremanagement goals

Scheduling regular meetings with case management staffto identify and resolve issues

Including case management in department meetings Collaboratively developing forums, such as daily care

coordination rounds, for discussing patient care progression with active participation by both nursesand case managers

Providing on unit work space for case management staff Regularly assessing effectiveness of care management

roles, structures, and processes.An example of one surveyis provided in Figure 1.

PARTNERSHIP AND THE EVOLVING ENVIRONMENT The new generation of case management and nursing mustprovide focused attention to meeting patient and familyneeds within a much abbreviated period of time and onsafely transitioning them to the next providers. This is excel-lent clinical care and has tremendous financial and compli-ance implications for the healthcare organization. Casemanagers and nurses play indispensable roles in patient caremanagement. Each brings a specialized focus and knowledgeto the process, creating synergy that is essential to success.The focus, knowledge, and partnership do not occur bychance but are the result of strategic and synergistic attentionby nursing and case management leaders. NL

References1. Centers for Medicare and Medicaid Services. The Medicare Recovery Audit

Contractor (RAC) program: an evaluation of the 3 year demonstration project.March, 2008. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Downloads/RecoveryAudit Demonstration_vj508.pdf. Accessed July14, 2012.

2. Centers for Medicare and Medicaid Services. 42 CFR 482.30. Condition ofparticipation: utilization review. (Electronic Code of Federal Regulations)http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R37SOMA.pdf. Accessed November 5, 2012.

3. Centers for Medicare and Medicaid Services. 42 CFR 482.43 Condition ofparticipation: discharge planning. (Electronic Code of Federal Regulations)http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R37SOMA.pdf. Accessed November 5, 2012.

4. Centers for Medicare and Medicaid Services. Medicare and You, 2013.http://www. medicare. gov/publications/pubs/pdf/10050.pdf. Accessed July14, 2012.

Kathleen A. Bower, DNSc, RN, FAAN, is the principal andco-owner of the Center for Case Management in Wellesley,Massachusetts, and can be reached at kbower@cfcm.com.

1541-4612/2012/ $ See front matterCopyright 2012 by Mosby Inc.All rights reserved.http://dx.doi.org/10.1016/j.mnl.2012.09.003

www.nurseleader.com Nurse Leader 29

The Crucial NursingCase Management PartnershipCASE MANAGEMENT IN TODAYS ENVIRONMENTTHE PARTNERSHIP WITH NURSINGPARTNERSHIP AND THE EVOLVING ENVIRONMENTReferences