C O L L A B O R A T I V E C A S E M A N A G E M E N T
Advancing Case Management Practice • Part I of II
By Marcia Colone, Ph.D., LCSW, Cindy Beemsterboer, RN, Susan Johanson, RN, MS and Steven McGaffigan, LCSW
“You can’t solve problems by using the same kind of thinking used when we created them” Albert Einstein
It is a common perception that healthcare systems are battle-weary
from persistent problems with capacity, length of stay (LOS), avoidable
delays, Emergency Department diversions, unavailable community
services and internal system issues. These systemic and situational
problems will only be solved by approaches that necessarily involve risk,
strategy and higher-level solutions.
Northwestern Memorial Hospital is a large academic, urban
medical center in Chicago where capacity and LOS are pressing issues.
In the spring of 2004, the organization’s
headlights were focused on identifying
strategies that would impact these issues and
yield sustainable and substantive results. It
was no surprise that the discussions included
the efficacy of the Case Management
program. Questions were raised about
whether the case management model, best
described as a collaborative practice model
which emphasized discharge planning and
utilization management, was effective. Was
care really being coordinated by case management? Should a different
model be used? Should a consultant be retained to assess the
department’s strengths and redesign the existing model?
The director of the department was involved in many of these
discussions. Colleagues from across the country were contacted to
discuss their models, outcomes and strategies on LOS and capacity.
Feedback from all points was secured and as the discussions continued
in the organization, the answer became very clear: the department
leadership could continue to participate in these discussions to
influence the strategies selected or, actually demonstrate an effective
strategy to address the larger institutional concerns.
Case management practice has great potential to offer new and
innovative solutions to the organization’s practice norms which are at
the heart of patient throughput issues. The daily work of case managers
in utilization management and discharge planning at the nursing-unit
level allow a unique perspective on practice conventions that contribute
to length of stay and inefficiencies.
THE EXPERIMENT
One hypothesis was that the bed capacity shortages and length of
stay excesses could be met by a more streamlined and efficient
coordination of care. The organization’s laser focus on these issues
made the time right to test this hypothesis with a small-scale pilot
demonstration of a new level of case management practice.
The hypothesis led to a redesign of the care management model that
included two vital components: a newly defined RN role and a process
identified as high-intensity escalation. The new role is that of a Care
Facilitator who is an RN with the clinical and case management expertise
to lead the multidisciplinary team. This Care Facilitator has a clear
3
understanding of the patient’s clinical status and a primary focus on
efficiently moving the patient through the hospital stay to a safe discharge
using high-intensity escalation with appropriate discretion. Leadership
skills combined with clinical expertise, utilization management
knowledge and discharge planning know-how are essential.
The Care Facilitator becomes the direct leader of the case
management team, which includes a Continuity of Care Nurse
Coordinator (COC) and social worker – existing roles that did not
change. The COC provides the utilization
management function and arranges the
homecare discharge plan. The social worker
provides an array of social work services such
as guardianships and conflict resolutions and
arranges all facility placements. Team
members are accountable to the Care
Facilitator and rely on her to coordinate the
multidisciplinary team and to resolve the
barriers to a safe and efficient discharge plan.
While the Care Facilitator provides direct
oversight of the case management staff on her team, she does not have
the same authority with the multidisciplinary team. She must rely on
bridge-building skills and expertise to facilitate issues and remove
barriers.
The second component of the model, high-intensity escalation,
defines the concept of escalation as an interventional process. In the
current model, staff members continually use escalation to eliminate
barriers. But with caseloads exceeding 25 patients, escalation becomes a
start-stop approach to problem-solving. By sheer volume, performance
of the many tasks associated with a caseload took precedence over the
smaller number but infinitely more complex barriers that required
escalation. Staff members may escalate an issue on one case and wait for
an answer and move on to another case that demands their attention.
High-intensity escalation involves the Care Facilitator, who makes the
assessment of the level of escalation needed based upon criteria such as
the nature of the barrier, what interventions have already been attempted
or failed and what are the next steps needed to ensure resolution. She
decides whether to escalate the issue/barrier or coach the team member
on how to further escalate the issue. Either way, there remains an
undistracted focus on a solution. Escalation requires substantial time,
expertise and perseverance. It requires judgment to initiate an escalation
and generate the follow through to complete resolution.
In the summer of 2004, this redesigned model was put into
production as a small-scale pilot. A successful pilot would mean that the
department would take control of its destiny and re-establish its value
to the organization. The new model, which included two RN Care
Facilitators, was piloted on a fast-paced neuroscience nursing unit
where care is provided for patients with very complex needs. This area
was well known in our utilization management program for high
(continued on page 4)
 C O L L A B O R A T I V E
Advancing Case Management Practice (continued from page 3)
resource utilization and opportunity for reduced LOS. As with many
pilot projects, pre-planning and communication is not the same as an
institution-wide rollout would be and this creates challenges. In this
case, the medical and hospital staff did not fully understand the Care
Facilitator role or the high intensity escalation process. Questions were
raised such as: Why were we asking so many questions, pushing so hard,
and pointing out problems? Why did we want to change rounds,
processes, and systems?
Examples of some of the changes that were made included the
format of rounds. New criteria was established which focused on
identifying pertinent information beginning with the anticipated
discharge date. Communication expectations were also set to ensure
that information shared at rounds was up to date and advanced the care
plan. The Care Facilitators were identified along with the Advanced
Practice Nurse as the facilitators of rounds. They ensure that the
meeting was productive and held staff accountable for timely
information sharing.
An additional change that was critical to the new process was the
chain of communication flow. This process change involved the Care
Facilitator who was the designated “Go To” person for the physicians
and team. She secured updates from the physician and communicated
those updates to members of the team. If there was an issue or barrier,
she would consult the physician and communicate to the team what
the next steps were to be. The Care Facilitators provided oversight to the
COCs and social workers as well as to the team.
THE OUTCOMES
The pilot model had challenges in the beginning. However, solutions
and expeditious trouble shooting were allies; information was the case
manager’s calling card. The case managers became part of the larger unit
care team. They educated the unit team on utilization management
principles and discharge planning concepts. Nurses and physicians were
coming to case managers for information. The Case Management staff
was involved in strategic changes in our own practice using outcome
data collected within our own program. For example, the avoidable-day
data indicated that Case Management staff was not being proactive in
identifying and resolving issues. This data was shared with staff and
strategies were discussed that would be more timely and effective.
Case managers were supported in approaching the Care Facilitators
early in a situation when a problem began to emerge versus waiting until
the problem was evident and perhaps more difficult to resolve.
Developing an open forum to discuss practice patterns with case
management staff and other staff was the key in raising awareness about
more effective strategies. For instance, data suggested that if the physical
therapy department could prioritize their patients beginning with those
who were likely being discharged the next day, LOS could be reduced.
Sharing the data made asking for that change in practice an easier
accomplishment. Data and discussion were the influential tools that
allowed case management to repair bridges that once went up in flames
and to build new bridges across waterways that were once nonexistent.
As the Care Facilitators proved their value to the multidisciplinary
and the case management teams, they quickly gained the reputation as
troubleshooters, who could escalate issues to successful resolution. Their
C A S E M A N A G E M E N T
growing reputation increased their influence with the team. The Care
Facilitators influence and direction became powerful tools to resolve
barriers and keep the patient on track to a safe and efficient discharge.
This new role provided the structure for the team to work in, while
it was the expected outcomes that provided the map. The key outcome
measures were LOS and Avoidable Days. These two indicators are
directly related to bed capacity. The redesign which used direct
interventions to resolve barriers coupled with high intensity escalation
processes led to reductions in length of stay. Access to automated
systems allowed the collection of avoidable days to become a reality.
This data was used to educate all members of the team as to the root
causes of delays and provided an opportunity to change practice
patters. The results after one year on a small scale garnered the support
needed to expand the model throughout the organization.
An early criticism of the model was the creation of another layer in
our case management team. There were those, including our own staff
members, who believed the COC and social worker had the expertise to
manage the patient along on the continuum, including escalations
when necessary. Although Case Management leadership had
confidence in the staff, experience showed that case managers were
challenged by the complexities of coordination and were not able to
escalate issues in a timely manner. Escalation could not be pursued
aggressively nor could they continue to focus on escalating issues on
one case only, because of demanding caseloads.
The power of care facilitation is proven by the outcomes generated
in our key measures of LOS and Avoidable Days. In one year’s time, the
pilot produced a length of stay reduction of 0.8 day overall. Avoidable
Days were reduced by one third. Outcomes exceeded expectations.
In the Spring 2006 issue, Part II will focus on the strategy to
expand the pilot throughout the organization and the lessons learned
along the way.
Marcia Colone, Ph.D., LCSW, is director of Case Management and the
External Transfer Program at Northwestern Memorial Hospital. She has
over 20 years of management experience.
Steven McGaffigan, LCSW, is manager of Case Management at
Northwestern Memorial Hospital. His Bachelors degree in Business
Administration is from the University of South Florida and his MSW is
from St. Louis University. He has 25 years of healthcare experience,
including 12 years in management roles. He holds the Accredited Case
Manager credential for hospital/health system case management.
Cynthia Beemsterboer, RN, BSN, ACM, is manager of Case Management
at Northwestern Memorial Hospital in Chicago. Her experience in case
management and utilization management spans more than 20 years. Ms.
Beemsterboer earned her BSN degree at Valparaiso (Ind.) University.
Susan Johanson is manager of Case Management-Women’s Health and
the External Transfer Program at Northwestern Memorial Hospital. She
has been in healthcare for 24 years, beginning her career as a nurse. She
received her diploma in nursing from Wesley-Passavant School of
Nursing in 1979. She complete a Bachelor’s degree in Health Arts in 1986
and MS degree in Health Services Administration from St. Francis
University (Joliet, IL) in 1989.