1. Powell, Suzanne K. RN, MBA, CCM, CPHQ
  2. Daniels, Stefani RN, MSNA, CMAC, ACM

Article Content

If there is one thing we can all agree on, it is that health care is changing at such a rapid pace, we can hardly keep up. As one regulation or process changes, there is an equal-and-opposite issue. Just look at some of the topics in this Professional Case Management Journal issue: an update on advocacy (that was so updated, we are looking at Part II in this issue), case management burnout, title protection, retail clinics, contracts, and length of stay (which ties to the Guest Editorial).

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Since the year 2000, there has been a National Case Management Week (this year, October 9-15, 2016). Perhaps, 15 years ago, most patients/clients did not know who case managers were, or what they did; but that has (in my experience) changed dramatically ... along with so much else.


Stefani Daniels is, perhaps, the most prolific voice on hospital case management. Here, she discusses the history of health care reimbursement and how case managers fit in. But this is more than a history lesson; it is also one case management expert's prediction of what may work in the future. Is some of it difficult to read? Yes. But it may just turn out that these scenarios may be part of the care management mix in the future. Certainly, we can't ignore the impending passage of the Medicare Conditions of Participation (CoP), the increased level of resources that will be needed to implement them, and that we will need additional help.


Whatever the changes bring, case managers have been the copilots in so many health care situations, coordinating, collaborating, connecting people with needed resources. You have earned every second of the National Case Management Week.


Guest Editorial

The health care marketplace was turned upside down in 1983 when the prospective payment system (PPS) was implemented. Since 1966, when Medicare and Medicaid went into effect, hospitals had been paid using cost-based reimbursement method-The more the hospitals billed, the more they got paid. There was no incentive to reign in excessive or wasteful costs. With the passage of the Tax Equity and Fiscal Responsibility Act of 1982, hospitals would now be paid under a PPS using a diagnosis-related group (DRG) category as the basis for determining the payment. Because each DRG had an associated expected length of stay (LOS), the executives at the time calculated that if Medicare is going to give the hospital a flat fee to cover its costs based on an expected LOS, then if the patient stays in the hospital for less than the expected LOS, the hospital would make a profit.


It sounds reasonable based on the reimbursement methodology, but it was flawed logic simply because it was assumed that if the patient stayed in the hospital fewer days than expected, then fewer resources would be consumed. With fewer resources consumed, the difference between Medicare's DRG reimbursement and the hospital's actual cost would result in an attractive margin that every hospital needs to financially thrive. The reality turned out to be quite different. Resource consumption did not decline and physicians continued to practice exactly the way they did pre-DRG-but they did it in fewer days. It is this legacy assumption that still pervades much of the thinking about hospital costs, margins, and length of stay, and hospitals are still feeling the pinch. (Daniels, 2008, p. 1)


Nevertheless, that was the belief at the time. To counteract the expected revenue shortfalls, the leaders at New England Medical Center (NEMC) believed that if there could be someone who could partner with a patient and his or her physician throughout the entire episode of care, it could expedite the care process by avoiding duplication of interventions and remove the gaps in communication as the patient moves from one area of the hospital to another. As a result, they redesigned the nursing delivery system and created a nursing case management model whereby the nurse who admitted the patient transformed into the patient's "nurse case manager" and followed the patient through discharge. The effect was immediate and articles soon appeared touting the success of the hospital's case management program. The NEMC model was the first generation of hospital case management programs-the clinical model in the taxonomy of hospital case management evolution (see Table 1).

Table 1 - Click to enlarge in new windowTABLE 1 Hospital Case Management Was Developed and Continues to Evolve According to Changing Demands Within the Health Care Marketplace

Other hospitals were not as lucky as NEMC and within 5 years of the introduction of the PPS, more than 1,000 hospitals went into bankruptcy and closed, were acquired, or converted to outpatient centers. Those that did survive took actions to quickly reduce expenses: Hospitals were "right-sized" to reduce overhead, employees were laid off, and services were consolidated or eliminated. Many organizations brought in consulting teams to help them through this period of turmoil and among them were those who had read about the success at NEMC. Using the concept of "case management" as a successful strategy to reduce LOS, and still under the assumption that reductions in LOS equaled reductions in cost, these consultants helped "reengineer" hospital operations by integrating the utilization review department with the social work department. With a little sprinkling of fairy dust, case management departments popped up all over the country. However, these so-called case management departments continued to do the functions of their predecessors-Nurses did utilization review and social workers continued to support the nursing staff to facilitate post-acute care placements. The original concepts of following a patient through the entire episode of care to reduce excessive or duplicate interventions and avoid delays got lost in the shuffle. We've been living with variations of this second-generation, functional model ever since (see Table 1).


It was also around this time that the industry saw changes in nursing and nursing delivery programs. It was the era of the transition from nursing as an occupation to a profession with a broadened body of knowledge, new standards of practice, and the growth of baccalaureate nursing programs. But it was also the era of nursing personnel shortages (Joint Commission on Accreditation of Healthcare Organizations, 2001). Hospitals adopted strategies to increase supply and retain staff. New positions, at lower salaries and adjunct to nursing were created, existing positions took on more responsibilities, nurses were recruited from other English-speaking countries, traveling nurses and agency nurses were hired, and new models of nurse staffing were introduced including 10- and 12-hr shifts and the so-called "Baylor plan" where nurses worked 24-hr weekend shifts and got paid for 32, or worked 32-hr weekend shifts and were paid at a full-time rate of 40 hr.


Concurrently, unit secretaries, positions that were created around the 1970s to relieve nursing of some nonclinical tasks, took on more tasks related to making arrangements for the patients discharge. Social workers, who, in addition to helping patients and their families understand a particular illness, work through the emotions of a new diagnosis and provide counseling about the decisions that need to be made, were available to the nursing staff to facilitate the placement of patients in nursing homes. Over time, these additional post-acute tasks morphed into total transfer of discharge planning and arranging responsibilities from the nurse to the social worker and, in many hospitals today, that is still the expectation.


In 1999, there was a significant, nationwide wake-up call about hospital safety and quality of care with the publication of Institute of Medicine's paper "To Err Is Human." That publication cited the alarming fact that tens of thousands of patients were dying in hospitals for reasons unrelated to the reason for their admission. Soon to follow was the Medicare Modernization Act of 2003 and the Deficit Reduction Act of 2005, which foretold the introduction of the Recovery Audit contractors, the Medicare Administrative contractors, and value-based purchasing. In combination, these tipping points presented the opportunity for prescient hospital executives and case management leaders to question the value of their current functional models and set the stage for the development of outcome models of case management.


The intent of these third-generation outcome models is very similar to the original intent of the nurse case management model at NEMC: Reposition the case manager to work with the physician and the care team to improve the clinical and financial outcomes of care associated with the patient's movement through the hospital stay. Although LOS remains a goal, especially in facilities where capacity and throughput issues are a challenge, today, hospital case managers are more focused on making sure that patients get the right care in the right place at the right time. They are empowered to question the value of what is perceived to be wasteful, excessive, or potentially harmful medical interventions; they will influence the use of evidence-based protocols whenever possible; they will engage patients to ensure that treatment plan reflects the patients' and families' preferences; and they will make sure that patients are not unnecessarily exposed to the quality, safety, and financial risks associated with hospitalization.


To accomplish these goals, the case manager must be visible and present on the units, to make rounds with the physicians and care team, and to participate in as much of the progression-of-care discussions as possible. As a result, hospital case management programs are in the midst of major transformation: They are reorienting the case manager to the role of care coordinator, restructuring resources so that the functions of utilization review are delegated to a team of highly proficient specialists, and transitioning the functional role of the master's prepared social service worker as arbiter of planning and arranging discharges to that of psychosocial counselor. Professional nurses are resuming their role as the primary discharge planners, and the tasks required to arrange the discharge are delegated to a group of post-acute support personnel. In this manner, the clinical responsibilities of the nurse are not impinged upon. It is this component of the transformation that presents the most challenges.


Nursing has long recognized that discharge planning begins at, on, or before admission. As the first nonmedical professional to encounter the hospitalized patient, the initial patient assessment is intended to trigger plans about what teaching and services the patient will possibly need to prepare him or her for transition when acute care needs are resolved. That "discharge planning is the responsibility of the professional nurse caring for the client or family" (Carpenito-Moyet, 2009, p. 24) is a standard of professional nursing practice has never been challenged. But I suspect that the presence of a case manager and the expanded role of the social worker have enabled nurses to withdraw from this basic responsibility.


This assumption is based upon experience as a nurse, former chief nursing executive, hospital administrator, and hospital case management consultant. For the last 20 years, I have traveled the country and have been engaged by hospitals of every type: small critical access hospitals, large academic teaching facilities, and community hospitals. And without exception, one of the major challenges encountered is chief nursing executives who push back on any suggestion that patients' nurses resume their rightful role as primary discharge planners. Even when the professional responsibilities of creating a discharge plan were differentiated from the supportive logistics of facilitating the plan, they still resisted.


The creation of a service corps to handle the logistics of post-acute needs is a fast-growing component of contemporary hospital case management programs. This was confirmed at this year's American Case Management Association conference, when many presenters, in describing their programs, included case management support staff-nonprofessionals charged with facilitating discharge plans. Today's case management departments are a compilation of several service activities and the fact that many hospitals are now incorporating a post-acute resource component is a progressive step in the right direction.


These post-acute resources seem to come in a variety of models: from unit-based or floating assistants, centralized post-acute resource centers (PARCs) located in a single hospital, or regional PARCs managing logistics for several facilities. No matter what the model, the support personnel whose background may be in practical nursing, emergency medical techs, or savvy unit clerks, probe the environment telephonically or electronically 7 days a week, often 12 hr a day, to locate and arrange post-acute community services in accordance with the submitted plan.


Surprisingly, residents, community-based primary care physicians, emergency department (ED) physicians, and hospitalists embrace the concept immediately. Having a "one-call does all" resource center to arrange an immediate referral to home care direct from the ED or the physician's office, to locate community resources and make appointments with clinics or medical homes, and to set up follow-up appointments with private community attendings are seen as value-added services.


Staff nurses continue to resist in many ways-some overt and some quite subtle. For example, they will complete the initial patient assessment, but the portion regarding psychosocial or potential discharge planning needs are left blank; they may skip over information requested that may signal progression of care obstacles, such as polypharmacy, health care literacy, multichronicity, level of cognition, or availability of family support; or they may persist in calling a case manager or social worker if their patients need a bedside commode when they go home.


In my ideal world of hospital care, the need for hospital case managers would be less than today. The patient's nurse could be the primary advocate, who makes sure the patient gets the most cost-efficient antibiotic, who makes sure that the patient is not exposed to multiple computed tomographic scans, who makes sure the patient ambulates to maintain functionality, who makes sure that the medical staff-approved protocol is followed, who questions the need for the Foley catheter, who makes sure the patient is not warehoused needlessly over the weekend because radiology will not do the test until Monday, who makes sure that the patient and the family understand the medications they must take when they get home, who ensures face-to-face handoffs so information is correctly shared, who advises the physician about complete and accurate documentation, and who makes sure that the patient and the family are ready for discharge. The reality is quite different, and nursing's staunch resistance to resume what has historically been a core competency of professional nursing is a disappointment.


As hospitals prepare to make leap from a fee-for-service environment to a fee-for-value milieu, hospital case management programs are preparing too. This means that there must be a mechanism to identify those patients whom would benefit from their services as care coordinators both in the hospital and, depending upon the model chosen, across the continuum of care. In the absence of predictive analytics, patients are identified by the complex nature of their treatment plan and need for coordination of services. Thus, it is safe to say that patients with disposition codes indicating home, home with home care or durable medical equipment, or return to an intermediate care facility, skilled nursing facility, or rehabilitation center would not typically require a care manager and their discharge plan could be developed by their staff nurse. Given the high probability of passage of the proposed discharge planning rules in the CoP, this shared responsibility between care managers and nurses will be essential for successful patient care transitions.


The professional practice of nursing continues to evolve with new opportunities under the Affordable Care Act, the rise of consumerism that accompanies the new high deductible health insurance plans, and the change in state statutes that have broadened the nurse's scope of practice. But the hospital industry in general and, in my opinion, hospital nursing services specifically have a hard time changing. Although there are pockets of progressive thinking and experimentation with new delivery models, the basic premise of professional nurses empowered to clinically and financially advocate for their hospitalized patients by ensuring that a safe, timely, and appropriate discharge plan is in keeping with the patients' preferences and agreed upon by the patients' care team has not been fully realized.




Carpenito-Moyet L. J. (2009). Nursing care plans & documentation. New York, NY: Lippincott Williams & Wilkins. [Context Link]


Daniels S. (2008, July 14). The myth of length of stay. Retrieved from HealthLeaders Media website:[Context Link]


Joint Commission on Accreditation of Healthcare Organizations. (2001). Health care at the crossroads strategies for addressing the evolving nursing crisis. Retrieved May 1, 2016, from[Context Link]