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From a practical viewpoint, the close relationships among utilization review, quality assurance/ improvement, infection control, discharge planning, social services, and medical records makes it impossible to separate them. Case management combines these traditionally isolated hospital functions into one department in order to perform many related functions simultaneously. It provides a much more effective and efficient method than can be accomplished by the traditional institutional approach.

For too long, institutions have utilized myopic vision as they have allowed the utilization review, quality assurance/improvement, infection control, discharge planning, social services, and medical records functions to exist as islands, assuming that only a casual relationship exists among them. In a system that has failed to combine the functions, it is entirely possible for a physician to be contacted about the same patient for multiple reasons on the same day by different nurses performing different concurrent review functions. There are major benefits to the medical staff when an institution uses the case management concept.

With the case management system, one nurse performs concurrent review relative to all of the areas simultaneously. The data related to these functions are recorded on a single review form. If it is necessary to contact a physician, all questions that need to be addressed are discussed in one telephone call. The physician is saved from what he or she perceives to be multiple "nuisance telephone calls." The result is that considerable time is saved by both the reviewing nurses and the physician.

In many institutions, there are separate medical staff committees for each of the functions. In the case management system, four medical staff committees are combined. It is possible to obtain more meaningful results from the single remaining committee meeting, while reducing physician meeting hours by as much as 75 percent.

If it's so simple, why have institutions failed to explore the possibility of integrating these functions? The answer is multifaceted:

* Institutional fear that such a plan simply won't work.

* Administrative fear of cost increases in potentially nonrevenue-producing areas.

* Belief of personnel that they cannot master the skills necessary to be a case management nurse, as opposed to a UR nurse, an infection control nurse, or a quality assurance nurse.

* Lack of a qualified individual who could assume the responsibility of formulating a plan of combining the functions and then overseeing integration and implementation of such a program.

Once an institution has decided to proceed with integration of the functions, a qualified physician and an RN department director must be available and agreeable to oversee the cross-training of the nursing component. RNs who have previously performed the separate functions of UR, infection control, quality assurance, and discharge planning must teach their areas of expertise to their peers. This is done under the guidance of the medical director and the case management department director.

In a like manner, each RN also becomes a student in those areas in which he or she has not had previous training. It will take possibly three months in each area for an RN to acquire sufficient knowledge to feel comfortable in performing job functions that she has not previously performed. Because all of the crosstrained RNs remain in the same department, there is the benefit of daily consultation as needed in any area in which the RN needs or desires further knowledge. This ongoing training and education helps to ensure that each individual, upon completion of the cross-training, can perform any of the functional duties.

In a 200-bed hospital with six to eight RNs, the process may well require 18 to 24 months to complete the cross-training. The funding and the time devoted to the development of this program will continually pay dividends to the institution. The program provides a relatively easy method of compliance with the many federal and state laws/mandates and accreditation agency regulations (i.e., state licensure and JCAHO accreditation). With cross-trained personnel, the problems of noncoverage in certain areas because of vacations and/or illness is solved, because more than one person can perform the needed task.

A close working relationship should be cultivated and maintained between the case management department and the following areas:

Medical Records Department

Review of medical records, both concurrently and retrospectively, is required daily in the case management process. The cooperation of the medical records department is essential in ensuring that the records can be acquired and utilized in a timely fashion.

Social Services

Because social services is involved, on many occasions, in the discharge planning process, close association of this service with the case management department helps to ensure that duplication of efforts does not occur, while close communication allows each to complement the other.

Patient Advocate Services

Many patient problems, both real and perceived, are related to utilization of hospital services. The patient advocate must have good rapport with the case management department to help ensure that the patient's concerns are addressed and that the patient is helped to understand hospital rules.

Medical Staff Secretary

The process of recredentialing of the medical staff is of utmost importance to the institution and must be performed in a timely and accurate fashion. Because quality assurance functions are the responsibility of the case management department, its relationship with the medical staff secretary needs to be one of understanding and coordination of roles.

The medical director must foster a close working relationship with the medical staff leadership, specifically, with the chief of the medical staff and/or the president of the medical staff. Additionally, it is necessary for him or her to work with medical staff officers to ensure proper selection of the case management medical staff members who have an interest in all of the review functions and who are willing to devote the time necessary to learn the processes. The medical staff must have a satisfactory comfort level with the entire process to ensure its support and participation. Without its support, the program would have little chance of success. The medical staff must understand that the quality assurance process is institutionwide and is being performed for only one purpose--to ensure the patient care being rendered meets accepted medical standards.

The medical staff must be assured that the review functions have physician input in quality assurance activities and that true peer review actually occurs. It is necessary that a physician, ideally, a medical director, assume the administrative role of coordinating all of the functions. He or she will be the person to whom all these department supervisors report.

Although Community Methodist Hospital has not experienced any significant problems since implementing the program, there is a potential for several difficulties to arise:

* Insufficient ongoing financial commitment from the hospital administration to ensure adequate staffing and technical support, without which the program is destined to fail.

* Lack of enthusiasm by the RN staff and/or the medical director to both teach and learn.

* Inability of the case management department director to display the necessary leadership to coordinate the program on a day-by-day basis.

* Turnover of RN staff members either during or after cross-training because of job transfer, illness, or relocation out of the community, in which case the cross-training process must be reinstituted.

* Lack of cooperation and support by the medical staff.

* Unwillingness of medical staff members of the case management committee to withstand the criticism inflicted on them by other members of the medical staff, particularly in early phases of instituting the program.

* Inability or lack of desire on the part of medical staff committee members to learn the process and to devote the time necessary to ensure the success of the program.

* Failure of the medical director to continually monitor the program and give assistance and support to the RN staff and to work daily with medical staff members to ensure their help and support for the program.

Given the above information, what is necessary to implement the program and ensure its success?

* Education of both hospital personnel and the medical staff on the program's necessity, as well as the methods used to implement it.

* Total administrative support, both philosophically and financially.

* Cross-training of nurses to perform utilization review, quality assurance/improvement, infection control, discharge planning, social services, and medical records functions.

* Construction of a concurrent review sheet in a manner that will clearly exhibit all the information retrieved by chart review. It must display the desired information on the initial review, while allowing continued concurrent review information to be entered as needed.

* A medical director who is willing and able to provide the assistance and guidance to ensure that program objectives are reached.

Although the case management department will not become a "revenue-producing center" in the true sense, it will be financially feasible and will more than pay its own way. The 'return will be reaped by providing expertise that will:

* Maximize payments from thirdparty payers.

* Retrieve payments due the institution that have been denied by third-party payers.

* Reduce patient length of stays by performing the groundwork of discharge planning at the time of the patient's admission.

* Provide savings in risk management.

Our case management system has been perfected as an organized approach to performing the multiple hospital functions enumerated above, while simultaneously meeting the many external constraints that hospitals presently face. Following a oneyear development, it has now been used effectively for five years. It is feasible, and it is workable. Those institutions that have not already combined at least some of the above functions would do well to consider the case management approach to total quality patient care.

Further Reading

The following additional sources of information on case management were obtained through a computerized search of databases, Copies of articles are available from the College for a nominal charge. For further information on citations, contact Gwen Zins, Director of Information Services, at College headquarters, 813/287-2000.

Schlackman, N. "The Quality Care Cycle." QRB 17(11):60-4, Nov. 1991.

Sherman,J., and Johnson. P. "Nursing Case Management." Quality Assurance and Utilization Review 6(4):142-5, Winter 1991.

Surles, R., and others. "Case Management as a Strategy for Systems Change." Health Affairs (Millwood) 11(1):151-63, Spring 2992.
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Author:Siedelmann, Janice
Publication:Physician Executive
Date:Mar 1, 1993
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