Prescription for Change

Dust off your old inpatient care management and uncover the ROI

by Loren Mann, MBA, MS

I’m currently working with a hospital that is looking at a potential opportunity of over 15,000 days avoided for inpatient stays, and $21 million saved—all from retooling its inpatient care management infrastructure. But many hospital leaders don’t immediately think about how care management improvements can have such a dramatic impact, mostly because past efforts have produced mixed outcomes. So often these improvements get put at the bottom of their to-do lists.

But successful care management can actually solve root issues around clinical variation, length of stay, cost-per-case, and denial rates—areas that seriously impact efficiency and quality, and can better position hospitals for shifting reimbursements. With such a high level of opportunity on the table, it’s important to know why care management hasn’t always worked, and what top-performing clients are doing about it.

Scrapping old-school care management

Inpatient care management has long been viewed as a necessary evil that only leads to a substandard level of coordination. But let’s dig deeper into some old-school practices and how to be more effective by sprucing up your approach to care management.

Old way: Utilization monitoring and discharge planning seldom meet

Traditionally, a nurse care manager has worked on specific tasks, without worrying about what the team next-door is doing. For instance, I have seen nurse care managers focus on utilization, which is great for denial prevention, but they are less concerned with discharge planning. Unfortunately, when staff has an overly-narrow focus, siloes naturally form and disruptions happen along the clinical or financial pathway.

To address this, a “blended” role is ideal, where nurses are cross-trained on utilization and discharge planning, and develop a high-level view on otherwise unfamiliar functions. For example, a dedicated nurse that manages the workflow for denials and appeals with input from a physician advisor, should also be familiar with clinical care guidelines and discharge planning. And likewise, those at the clinical front lines should understand the denials process and leverage that financial training for more appropriate admissions and discharges, and flag any cases that might cause a reimbursement issue down the road.

Old way: Social workers run the lion’s share of care management functions

While nurses have emerged as core care management players, most responsibilities over the years fell to social workers—primarily because they were affordable for hospitals to hire. But with the wide range of job duties that contribute to successful care management, this was a sure recipe for ineffective patient coordination, not to mention staff burnout. Today’s social workers should be focused on what they are trained to do—assessing and supporting patients’ psychosocial needs—not spending time on care management tasks that other staff can easily and more quickly support, like appointment scheduling.

To that end, hospital leaders should promote a top-of-license staffing structure with a range of skillsets. Across departments, we like to see nurses and social workers certified in care management, physician advisors, and administrative care assistants—the latter taking care of critical tasks like transfers, documents, appointments, and escalating issues as needed.

Old way: Each facility is on its own with care management

Besides site-level divisions which I mentioned, large-scale siloes from facility to facility can prevent care managers from taking patients on a high-quality, cost-effective journey. Here’s a common example: John Smith at ‘Facility A’ manages all the nurses responsible for care management at his facility, and Jane Doe does the same for ‘Facility B.’ But when a patient is transferred from A to B, there’s no protocol for what to do with that patient, or even how to provide the best form of treatment. Without a system-level model, the experience and standards of care can vary widely for patients who are transferred from one site to the next.

To prevent such gaps, I recommend creating system-wide standardized care protocols to ensure smooth patient transitions and also make it easy for staff to float between facilities and improve coverage across the system. And in addition to leadership on a unit level and a director of care management at each facility, we like to see regional leadership over all sites—inpatient, ambulatory, outpatient, community, and post-acute—to measure performance across the board, and provide oversight on effective discharge planning and transfers.

Every hospital and health system has its own path to effective care management. But breaking down historical siloes—across functions, departments, and facilities—is what truly separates old school practices with an approach that leads to major savings, increased productivity, and more satisfied staff and patients.

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