1. McHale Ramey, Marianne RN, ACM, CPUR

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A few years ago, 20 years to be exact, I wrote an article, titled "Diamonds in the Rough." In that article, I opined about the opportunity for the case manager to be more closely aligned with the physician caring for the patient and the value that would be derived from such a partnership. Some of the benefits cited contributed to a hassle-free hospital environment where quality outcomes reflect processes that work as they were intended. There is the accountability of process owners when barriers to efficient care exist, where only services that contribute to the desired outcome for a hospital stay are prescribed. But, alas, in many hospitals where I have had the privilege of consulting, very little has changed over the years.


In many hospitals, the case manager is typically a registered nurse (RN) who functions as the "Travel Agent" with primary responsibility for making the arrangements needed to enact a discharge plan. This is a legacy model that harkens back to the 1990s. While enacting a discharge plan requires coordination and expertise, little of the work requires a professional license. And so, I must ask, why do we need nurse and social work (SW) case managers?


If the multidisciplinary team is assessing for posthospital needs, and nurses, physicians, and various disciplines involved in the care of the patient are monitoring the patient's progress and continue to evaluate the need for post-acute care and services, why do I need an RN to be the hunter and gatherer of those services? The answer is, "I don't"! Savvy support staff can do the work required to implement post-acute care and services; that type of work does not require a professional license.


Do we need SWs to address complex patient/family dynamics, end-of-life care, and other psychosocial issues? Yes. Do we need a shift in care management focus from all hospitalized patients to the complex, chronically critically ill population who are typically underinsured or uninsured. Yes. But once the care team makes the determination that the "basic" post-acute services, such as home health, skilled nursing, rehabilitation placement, durable medical equipment, or transportation that are most often prescribed require, are all that is required postdischarge, I challenge the assumption that an RN or SW is needed.


So, what is to become of the professional hospital case manager? To quote Dr. Seuss, "Oh, the Thinks you can think up if only you try." I argue that now is time to move the RN case manager into the community to support the transition of care and to manage the ongoing needs for the sickest and neediest of the population served. In this capacity, critical function should focus on the identification and management of high-risk patients with frequent emergency department visits or readmissions and to understand and to address social determinants of health that are key contributors to failed discharge plans.


Is the patient cured after 30 days when the funding to follow them runs out and the penalties expire? No. The case manager coordinates with others involved in managing patient care, be it the primary care provider (PCP), the advanced practice registered nurse (ARNP), the specialist, the accountable care organization (ACO), or the insurance company, and help the patient and family navigate the complexities of our health care system. When the hospital sponsors the professional case manager, they can be the single consistent resource who knows the patient's history, follows them regularly, and partners with the PCP to manage and coordinate care until intensive care management is no longer needed. A case manager is an essential contributor in facilitating communication between all the well-intentioned providers who never seem to talk to each other and have disparate information technology systems that, despite all being supported by the same platform, never provide the vital information needed for care continuity in a meaningful and user-friendly way.


How might this model look in the real world? We are all taught that discharge planning begins on admission and is initiated within 24 hr, usually by the admitting nurse. The initial assessment is complete and concise and asks all the right questions so that there is no need for a case manager to do another evaluation. When appropriate, physical or respiratory therapists provide another assessment unique to their specialty. If each is assessing patient need, there is no justification for the case manager to do yet another. There are very progressive organizations that have empowered these disciplines to formulate their recommendations for post-acute care and make the arrangements for those services, thereby eliminating the middleman from the transaction!


The resources required to accomplish such a feat must be provided along with the necessary training, but support staff for these services can develop the expertise and are perfectly capable of making sure the right services are being requested and that their portion of implementing the post-acute plan is accurate, timely, and effective. All information is documented and accessible to the team. The nurse is then responsible for ensuring all elements of the plan are in place, and all providers are notified and ready to provide services at the time of discharge. This approach requires that the electronic medical record is user-friendly and that all information related to the discharge plan is compiled in one place that all users can easily access and is provided to the patient in an easily understandable form. (I hear you laughing!)


This model will break down when communication fails. Ideally, it is the charge nurse and the physician who are responsible for knowing the mantra coined by the late Karen Zander: "the Plan for the stay, the plan for day, the plan for the way and the plan for the pay for every patient." This model puts the bedside caregivers in charge of knowing their patients and how the patient's care will progress toward the eventual discharge and transition of care to post-acute providers.


But, you say, there are so many moving parts ... authorizations, preferred providers, patient choice, multiple referrals, transportation, community resources, and patient and family engagement. Tackling that level of responsibility may not be feasible but do not despair. We can still support the implementation of a post-acute plan by developing a post-acute resource center (PARC) where all the logistics of implementing the plan happen in a centralized location by a well-trained competent staff who have all the information needed to put the plan into motion. And as a bonus, this service is available to the hospital's community physicians and providers who struggle with the complexities of obtaining resources and services for their patients.


Case managers are too valuable of a resource to be stuck behind a computer and on the phone. Move the resource to where it is most needed, the next frontier, out of the hospital, and into the community. This is what we must do. How we meet this challenge is for our profession to define. For if we do not define it, someone else will.