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It is the ultimate goal of any case management team to facilitate the delivery of high-quality care in a cost-effective manner, and to promote positive healthcare outcomes. Hospital case management is episodic by design and typically focused on the acute, emergent or elective clinical care required for the patient upon arrival.

The hospital environment itself is unique, as it features a host of professionals and practitioners with expertise across multiple fields, all of whom bring together their expertise and offer service that typically concludes with the satisfaction of patients and their families. A hospital case management team must manage episodes of care that are at the crossroads of the clinical, financial, social and regulatory needs of multiple stakeholders, both within and outside of the facility.

To be truly effective and to achieve varied and often disparate goals, the case management team also must be seen and endorsed by the c-suite executive level of the hospital, with system-wide initiatives providing full, active and ongoing support of the immediate leadership team.  

One question often asked is this: to whom should the case management team report? It’s a very good question! Case management should report to the person within the c-suite most inclined to embrace the needs of the primary service (in other words, the executive who also will value and seek input from other members of the executive team who have a vested interest in some part of the services provided by the case management team). The c-suite executive who takes on this role also must be very comfortable working in sensitive and sometimes volatile situations.

As you can imagine, the case management team, working in the best interests of the patients and the organization, often should be delivering messages to physicians, patients, nursing, allied health professionals and ancillary departments requiring them to change adverse behaviors and attitudes (or adjust patterns to better meet the ultimate goal of optimum patient care and well-being). Additionally, each member of the c-suite should be available to the designated executive case management lead when support is needed to drive departmental change or to deliver factual, data-driven outcomes requiring action by physician staff. 

The case management department typically does not have any authority assigned to them, and therefore it must lead by applying expertise to each unique patient situation and then assisting in the development of a realistic, achievable plan that meets the patient’s needs.  Case management team members achieve results through pursuing clearly identified goals to drive success. This also requires excellent communication, collaboration, and coordination across departments and specialties, including patient access, finance, compliance, nursing, physicians, external service providers, insurers, pharmacy, dietary and rehabilitation services, and many more. They must act with the intent of excellence and deliver service and information to the team at large, thus capitalizing on each team member’s expertise.

Case management has the potential to impact patients in the most positive and beneficial ways, but that may require that individuals or departments deliver their unique services in new ways and in multiple settings (to include post-care services),or at different times than those to which they are accustomed. This is where communication between the case management director and the c-suite executive is crucial. The case management director should always alert the c-suite leader to potentially difficult situations, which also can be seen as opportunities for behavioral and/or organizational improvement. 

Case management team members are in a unique position of influence within the care team.  They work with physicians and nursing on plans of care to support patient goals and develop discharge plans, with an eye on transition planning and readmission prevention. They also impact the production of more robust documentation as they perform utilization review activities to establish status based on medical necessity, and they communicate with payers initially and concurrently regarding the condition and ongoing care needs of patients. The utilization process is the hospital’s first line of defense against audit contractor recoupment. The team also must communicate with ancillary service providers to establish present and potential future needs of patients for care, education or placement.

The case management department should be aware of each patient in the hospital and actively screen every admission, discharging only when appropriate in order to meet the demands represented by all of their competing priorities. A strong, proactive and involved c-suite also is essential for the ultimate success of the team and the hospital in a way that affects bottom-line outcomes.  The c-suite and the case management team must work together to break down barriers and operate with creativity to achieve their mutual goals.

About the Author

Donna McLean is an RN, BSN, MBA, a licensed registered nurse in Georgia and Michigan and a Certified Case Management Administrator. Donna has 18 years of clinical experience as a critical care RN and nurse manager, as well as more than 10 years of progressively more complex leadership experience in hospital case management as a case management leader, manager, director and vice president, in mid-sized to large healthcare facilities, multi-hospital systems and teaching hospitals. She has experience as a sole proprietor consultant assisting hospitals in development and enhancement of case management services. Donna is a co-founder and managing partner with DSE Associates.

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Donna McLean, RN, MBA, CMAC

Donna McLean, RN, MBA, CMAC, is president and co-founder of DSE Associates — Healthcare Case Management Solutions. Donna’s 25 years of firsthand experience in providing healthcare services qualifies her to understand the needs and requirements of clients in the healthcare arena.

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