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The case manager connection: Taking a leadership role to improve patient outcomes
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The Case Manager Connection Taking a Leadership Role to Improve Patient Outcomes Kim Schuetze, ACSW, CCM, and Beverly Cunningham, MS, RN
Case managers are increasingly assuming leadership roles in hospitals and other acute care facilities as coordinators of care who link practices to improved patient outcomes. Through their work with multidisciplinary teams, case managers are uniquely positioned to provide this direction to promote greater collaboration among physicians, nurses, clinicians, and other stakeholders. In fact, the more that case managers assume their leadership role, the closer they will be working with nurse leaders toward better communication and greater collaboration to establish outcomes-based practices.
48 Nurse Leader
The leadership approach taken by both case managers and nurse managers is essential given the realities of patient care today: increased complexity of medical conditions, a shortage of nurses on the hospital floor, and treatment by more than one doctor or specialist. At the same time, hospitals and other acute care facilities are striving to achieve their goals of improving patient outcomes and satisfaction, while controlling costs by making care more efficient and effective. Both of these leaders— case managers and nurse managers—have specific roles in improving these outcomes. Case managers —and in particular certified case managers who have demonstrated that they possess the requisite knowledge, skills, and experience—are responsible for directing the assessment, implementation, and evaluation of the overall plan of care. The case manager looks at issues from how well physician orders are carried out to identifying the potential for complications. Many times, the February 2007
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overall responsibility of the case management department is to work closely with nursing leadership and physicians to establish data sets and indicators to evaluate outcomes of the overall care. Case managers also contribute directly to reduction of costly delays in treatment by monitoring and coordinating all facets of the care plan. For example, as occurred at one hospital recently, when a medication was not administered as ordered by the doctor, surgery had to be rescheduled, which unnecessarily extended the patient’s stay by a day. Case management leadership can help avoid these snags in treatment that run counter to the hospital’s goals and undermine patient satisfaction. Working closely with the nurse manager on the floor, case managers provide valuable feedback so that staff nurses can understand their impact on clinical and financial outcomes. “Today, the roles and responsibilities of case managers include focusing on utilization management, case management, disease management, and the evaluation of these initiatives within their practice. This is an opportunity for case managers to exhibit their leadership, working with physicians, nurses, and other clinicians,” observed Mindy Owen, RN, CRRN, CCM, Immediate Past Chair of the Commission for Case Manager Certification (CCMC), and principal of Phoenix HealthCare Assoc. LLC, a Coral Springs, Floridabased consulting firm specializing in case management, disease management, and managed care development and education. “Case management leadership is grounded in integration with all of the healthcare practitioners involved and with community resources—while also staying focused on both consumer- and hospital-goals. Through collaboration and coordination, case managers are in a unique position to direct and streamline a complex process.” The case manager, who is responsible for the coordination of care, exhibits leadership that is different, yet highly complementary, from that of others in the hospital setting, such as the charge nurse who oversees a particular floor or a shift nurse who directs the staffing on a particular shift. Case management leadership through collaboration is unique within the hospital environment where other professionals are directing their own disciplines. In the hospital and acute care setting, case management is essential to address the demands of care within dynamics that include other stakeholders from the patients’ families to insurers and employers. Key to the case management process is gathering information from an interdisciplinary team to keep all parties informed and to lead the discussion for discharge planning. Without that connection, however, there exists a greater possibility of unnecessary duplication of services or even the potential for a serious medical error.
COLLABORATING WITH NURSE LEADERS The collaboration between case managers and nurses on the hospital floor is an important working relationship, built on the strength of their leadership and mutual respect. Many case managers come from a nursing backFebruary 2007
ground, which also helps establish common ground. Case managers also come from other highly respected professional backgrounds, including social work, occupational therapy, vocational rehabilitation, and mental health counseling. Through licensure in their professions and certification as case managers, they establish a level playing field with other credentialed professionals. Together, nurses and case managers have a comprehensive view that enhances patient treatment and satisfaction. For example, a nurse at the patient’s bedside must focus on the treatment episode in that moment; that is, the patient’s immediate need during the nurse’s shift. The case manager, meanwhile, views the entire episode of care, from admission through treatment and postdischarge. Thus, while the case manager is coordinating the care of patients, the nurse manager is empowering the nursing staff to assure that outcomes are met, both from the care plan for the day, as well as from the care plan for the entire stay. Nurses and case managers share a common bond of patient-centered care, which is a critical link in assuring the achievement of overarching goals. These goals include improving efficacy of treatment and patient satisfaction and, ultimately, promoting the best use of costly and scarce treatment resources. The expectation for the Certified Case Manager, in particular, is that he is a leader, capable of taking on responsibility for the planning and monitoring of the care plan and the analysis of the outcomes—and then sharing those outcomes with other professionals so that they can become the basis of best practices. Because case managers see the whole picture of patient treatment, from admission to postdischarge, they have a unique perspective to lead endeavors for grounding practices in outcomes. Through their leadership, case managers communicate to the staff how these outcomes were achieved, bringing the process full circle so that best practices can be adopted. One way this is accomplished is through weekly multidisciplinary patient-care rounds. Leadership of these rounds varies from hospital to hospital; in some, nurses may lead them, and, in others, that role is assumed by the case manager. Regardless of how the rounds are led and structured, the focus is on planning for care during the hospitalization of the patient. All parties benefit from a free-flowing exchange of information as the care plan and discharge plan are developed. Case management leadership and nursing leadership facilitate success of the collaboration. That success is determined, however, by patient outcomes.
CASE MANAGEMENT ROLES The foundation of case manager leadership is the responsibility of ensuring that patients get the care, treatment, and other resources that they need. The case manager’s advocacy role is fundamental to the field of practice. In addition, case managers have a responsibility to act as stewards of scarce and costly health care resources. These roles contribute directly to positive clinical, financial, and patient-satisfaction outcomes in hospital and acute care environments.
Nurse Leader 49
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Case management leadership is also exhibited through the essential activities of case management.1 They are: • Assessment – Collecting in-depth information about a client’s situation and functioning to identify individual needs • Planning – The process of determining and documenting specific objectives, goals, and actions • Implementation – Executing and documenting specific case management activities or interventions • Coordination – Organizing, securing, integrating, modifying, and documenting the resources necessary to accomplish the goals in the case management plan • Monitoring – Gathering sufficient information from all relevant sources and documenting information regarding the case management plan • Evaluation – The process, repeated at appropriate intervals, of determining and documenting the effectiveness of the case management plan • Outcomes – The process of measuring the interventions to determine the outcomes of case management involvement • General – Activities and interventions that are performed across case management practice and process Another expectation for certified case managers is that they will uphold the highest professional and ethical standards and commit to ongoing professional development through continuing education. This further enhances a case manager’s value to the hospital organization.
IMPROVING MEDICAL COMPLIANCE Case management leadership also speaks directly to improving outcomes through education and empowerment of patients, which is another important component of advocacy. When patients or their families have a better experience communicating with doctors and other members of the treatment team, their satisfaction typically improves. Improved satisfaction directly relates to better compliance with medications prescribed as well as doctors’ orders for diet, exercise, and follow-up visits. With greater adherence and communication, efficacy of treatment improves, which further enhances patient satisfaction—and which may help avoid a repeat hospital visit or prevent a potential medical error. “Facilitating communication is a skill that case managers provide to the process,” Owen added. “In an integrated and collaborative model, everyone benefits from effective and efficient communication, which ultimately improves overall patient-related outcomes.” To illustrate the importance of case management services and how case managers exhibit leadership in hospitals and other acute care settings, consider the story of a 21year-old woman with diabetes. Uninsured and nonadherent with medical treatment, the woman used the hospital emergency department (ED) to receive primary care and typically would come to the hospital when she was in crisis, which resulted in admission. Working together, the case manager in the ED and the case manager on the unit where the woman was treated 50 Nurse Leader
decided to take on the responsibility of developing a case management plan, which included enrolling her in an indigent clinic for ongoing treatment where she could obtain medications at a discounted price. The case management plan (which would be triggered when the woman checked into the ED) also included counseling and education for the woman and her family. Through their initiative and leadership, a case management plan was established to encourage the woman to adopt better self-care, to take responsibility for her condition, and to discourage her dependence on the ED for primary care treatment.
CASE MANAGEMENT AFTER DISCHARGE Certified case managers extend their leadership through discharge. They understand that the efficacy of treatment received in the hospital is improved when the patient is able to transition successfully to the next level of care. This may include discharge to rehabilitation, extended care, or other treatment facility, or to the home environment where the patient may be cared for by family or a home health care provider. At this transition in the care plan, case managers may interact with each other, including a hospital-based case manager and a medical case manager for a home health care company. This brings the treatment goals full circle: better adherence with the medical regime postdischarge decreases the chances of an unnecessary hospitalization in the future. In today’s hospital environment, case managers act as a lynchpin among valuable care and treatment resources. With clinical knowledge and experience in nursing, social work, or another related specialties, their backgrounds are complementary with the nurses with whom they work most closely. Their unique brand of leadership is grounded in outcomes-based practice, helping all parties in the treatment team to work together more efficiently and communicate more openly to improve patient outcomes and preserve valuable care resources. Reference 1.
Commission for Case Manager Certification, CCM Certification Guide: 5-6. Available at: http://www.ccmcertification.org/ pages/14frame_set.html. Accessed December 20, 2006.
Kim Schuetze, ACSW, CCM, is a medical social worker with Floyd Memorial Home Health in New Albany, Indiana, and has 20 years’ experience in the health care arena, including more than 15 years in hospital social work. She is the chair of the Commission for Case Manager Certification (CCMC). Beverly Cunningham, MS, RN, is associate administrator, clinical performance improvement (which includes responsibility for case management) for Medical City Dallas Hospital. She is also Chair-Elect of the Commission for Case Manager Certification (CCMC). The authors can be reached through Patricia Crisafulli at [email protected]. 1541-4612/2007/ $ See front matter Copyright 2007 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl.2006.07.013
February 2007
1/26/07
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Page 48
The Case Manager Connection Taking a Leadership Role to Improve Patient Outcomes Kim Schuetze, ACSW, CCM, and Beverly Cunningham, MS, RN
Case managers are increasingly assuming leadership roles in hospitals and other acute care facilities as coordinators of care who link practices to improved patient outcomes. Through their work with multidisciplinary teams, case managers are uniquely positioned to provide this direction to promote greater collaboration among physicians, nurses, clinicians, and other stakeholders. In fact, the more that case managers assume their leadership role, the closer they will be working with nurse leaders toward better communication and greater collaboration to establish outcomes-based practices.
48 Nurse Leader
The leadership approach taken by both case managers and nurse managers is essential given the realities of patient care today: increased complexity of medical conditions, a shortage of nurses on the hospital floor, and treatment by more than one doctor or specialist. At the same time, hospitals and other acute care facilities are striving to achieve their goals of improving patient outcomes and satisfaction, while controlling costs by making care more efficient and effective. Both of these leaders— case managers and nurse managers—have specific roles in improving these outcomes. Case managers —and in particular certified case managers who have demonstrated that they possess the requisite knowledge, skills, and experience—are responsible for directing the assessment, implementation, and evaluation of the overall plan of care. The case manager looks at issues from how well physician orders are carried out to identifying the potential for complications. Many times, the February 2007
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overall responsibility of the case management department is to work closely with nursing leadership and physicians to establish data sets and indicators to evaluate outcomes of the overall care. Case managers also contribute directly to reduction of costly delays in treatment by monitoring and coordinating all facets of the care plan. For example, as occurred at one hospital recently, when a medication was not administered as ordered by the doctor, surgery had to be rescheduled, which unnecessarily extended the patient’s stay by a day. Case management leadership can help avoid these snags in treatment that run counter to the hospital’s goals and undermine patient satisfaction. Working closely with the nurse manager on the floor, case managers provide valuable feedback so that staff nurses can understand their impact on clinical and financial outcomes. “Today, the roles and responsibilities of case managers include focusing on utilization management, case management, disease management, and the evaluation of these initiatives within their practice. This is an opportunity for case managers to exhibit their leadership, working with physicians, nurses, and other clinicians,” observed Mindy Owen, RN, CRRN, CCM, Immediate Past Chair of the Commission for Case Manager Certification (CCMC), and principal of Phoenix HealthCare Assoc. LLC, a Coral Springs, Floridabased consulting firm specializing in case management, disease management, and managed care development and education. “Case management leadership is grounded in integration with all of the healthcare practitioners involved and with community resources—while also staying focused on both consumer- and hospital-goals. Through collaboration and coordination, case managers are in a unique position to direct and streamline a complex process.” The case manager, who is responsible for the coordination of care, exhibits leadership that is different, yet highly complementary, from that of others in the hospital setting, such as the charge nurse who oversees a particular floor or a shift nurse who directs the staffing on a particular shift. Case management leadership through collaboration is unique within the hospital environment where other professionals are directing their own disciplines. In the hospital and acute care setting, case management is essential to address the demands of care within dynamics that include other stakeholders from the patients’ families to insurers and employers. Key to the case management process is gathering information from an interdisciplinary team to keep all parties informed and to lead the discussion for discharge planning. Without that connection, however, there exists a greater possibility of unnecessary duplication of services or even the potential for a serious medical error.
COLLABORATING WITH NURSE LEADERS The collaboration between case managers and nurses on the hospital floor is an important working relationship, built on the strength of their leadership and mutual respect. Many case managers come from a nursing backFebruary 2007
ground, which also helps establish common ground. Case managers also come from other highly respected professional backgrounds, including social work, occupational therapy, vocational rehabilitation, and mental health counseling. Through licensure in their professions and certification as case managers, they establish a level playing field with other credentialed professionals. Together, nurses and case managers have a comprehensive view that enhances patient treatment and satisfaction. For example, a nurse at the patient’s bedside must focus on the treatment episode in that moment; that is, the patient’s immediate need during the nurse’s shift. The case manager, meanwhile, views the entire episode of care, from admission through treatment and postdischarge. Thus, while the case manager is coordinating the care of patients, the nurse manager is empowering the nursing staff to assure that outcomes are met, both from the care plan for the day, as well as from the care plan for the entire stay. Nurses and case managers share a common bond of patient-centered care, which is a critical link in assuring the achievement of overarching goals. These goals include improving efficacy of treatment and patient satisfaction and, ultimately, promoting the best use of costly and scarce treatment resources. The expectation for the Certified Case Manager, in particular, is that he is a leader, capable of taking on responsibility for the planning and monitoring of the care plan and the analysis of the outcomes—and then sharing those outcomes with other professionals so that they can become the basis of best practices. Because case managers see the whole picture of patient treatment, from admission to postdischarge, they have a unique perspective to lead endeavors for grounding practices in outcomes. Through their leadership, case managers communicate to the staff how these outcomes were achieved, bringing the process full circle so that best practices can be adopted. One way this is accomplished is through weekly multidisciplinary patient-care rounds. Leadership of these rounds varies from hospital to hospital; in some, nurses may lead them, and, in others, that role is assumed by the case manager. Regardless of how the rounds are led and structured, the focus is on planning for care during the hospitalization of the patient. All parties benefit from a free-flowing exchange of information as the care plan and discharge plan are developed. Case management leadership and nursing leadership facilitate success of the collaboration. That success is determined, however, by patient outcomes.
CASE MANAGEMENT ROLES The foundation of case manager leadership is the responsibility of ensuring that patients get the care, treatment, and other resources that they need. The case manager’s advocacy role is fundamental to the field of practice. In addition, case managers have a responsibility to act as stewards of scarce and costly health care resources. These roles contribute directly to positive clinical, financial, and patient-satisfaction outcomes in hospital and acute care environments.
Nurse Leader 49
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Case management leadership is also exhibited through the essential activities of case management.1 They are: • Assessment – Collecting in-depth information about a client’s situation and functioning to identify individual needs • Planning – The process of determining and documenting specific objectives, goals, and actions • Implementation – Executing and documenting specific case management activities or interventions • Coordination – Organizing, securing, integrating, modifying, and documenting the resources necessary to accomplish the goals in the case management plan • Monitoring – Gathering sufficient information from all relevant sources and documenting information regarding the case management plan • Evaluation – The process, repeated at appropriate intervals, of determining and documenting the effectiveness of the case management plan • Outcomes – The process of measuring the interventions to determine the outcomes of case management involvement • General – Activities and interventions that are performed across case management practice and process Another expectation for certified case managers is that they will uphold the highest professional and ethical standards and commit to ongoing professional development through continuing education. This further enhances a case manager’s value to the hospital organization.
IMPROVING MEDICAL COMPLIANCE Case management leadership also speaks directly to improving outcomes through education and empowerment of patients, which is another important component of advocacy. When patients or their families have a better experience communicating with doctors and other members of the treatment team, their satisfaction typically improves. Improved satisfaction directly relates to better compliance with medications prescribed as well as doctors’ orders for diet, exercise, and follow-up visits. With greater adherence and communication, efficacy of treatment improves, which further enhances patient satisfaction—and which may help avoid a repeat hospital visit or prevent a potential medical error. “Facilitating communication is a skill that case managers provide to the process,” Owen added. “In an integrated and collaborative model, everyone benefits from effective and efficient communication, which ultimately improves overall patient-related outcomes.” To illustrate the importance of case management services and how case managers exhibit leadership in hospitals and other acute care settings, consider the story of a 21year-old woman with diabetes. Uninsured and nonadherent with medical treatment, the woman used the hospital emergency department (ED) to receive primary care and typically would come to the hospital when she was in crisis, which resulted in admission. Working together, the case manager in the ED and the case manager on the unit where the woman was treated 50 Nurse Leader
decided to take on the responsibility of developing a case management plan, which included enrolling her in an indigent clinic for ongoing treatment where she could obtain medications at a discounted price. The case management plan (which would be triggered when the woman checked into the ED) also included counseling and education for the woman and her family. Through their initiative and leadership, a case management plan was established to encourage the woman to adopt better self-care, to take responsibility for her condition, and to discourage her dependence on the ED for primary care treatment.
CASE MANAGEMENT AFTER DISCHARGE Certified case managers extend their leadership through discharge. They understand that the efficacy of treatment received in the hospital is improved when the patient is able to transition successfully to the next level of care. This may include discharge to rehabilitation, extended care, or other treatment facility, or to the home environment where the patient may be cared for by family or a home health care provider. At this transition in the care plan, case managers may interact with each other, including a hospital-based case manager and a medical case manager for a home health care company. This brings the treatment goals full circle: better adherence with the medical regime postdischarge decreases the chances of an unnecessary hospitalization in the future. In today’s hospital environment, case managers act as a lynchpin among valuable care and treatment resources. With clinical knowledge and experience in nursing, social work, or another related specialties, their backgrounds are complementary with the nurses with whom they work most closely. Their unique brand of leadership is grounded in outcomes-based practice, helping all parties in the treatment team to work together more efficiently and communicate more openly to improve patient outcomes and preserve valuable care resources. Reference 1.
Commission for Case Manager Certification, CCM Certification Guide: 5-6. Available at: http://www.ccmcertification.org/ pages/14frame_set.html. Accessed December 20, 2006.
Kim Schuetze, ACSW, CCM, is a medical social worker with Floyd Memorial Home Health in New Albany, Indiana, and has 20 years’ experience in the health care arena, including more than 15 years in hospital social work. She is the chair of the Commission for Case Manager Certification (CCMC). Beverly Cunningham, MS, RN, is associate administrator, clinical performance improvement (which includes responsibility for case management) for Medical City Dallas Hospital. She is also Chair-Elect of the Commission for Case Manager Certification (CCMC). The authors can be reached through Patricia Crisafulli at [email protected]. 1541-4612/2007/ $ See front matter Copyright 2007 by Mosby Inc. All rights reserved. doi:10.1016/j.mnl.2006.07.013
February 2007