Hardwiring Excellence into Care Coordination

A total transformation of traditional case management assumptions is essential to thrive in the new marketplace of value-based care. 

It started out as an innovative nursing care model in the early 1980s and moved to a discharge planning/utilization review model incorporating several peripheral activities after the DRG fiscal meltdown. It then shifted to an emphasis on achieving outcomes following the publication of To Err is Human; and now, after 30 years, hospital case management is shedding its extraneous baggage to concentrate on its primary founding activity: care coordination.

It took three decades to come full circle, but the preparations for a value-based healthcare environment have opened the eyes of many hospital leaders who suddenly recognize the essential value of a care coordination approach to manage selected patients across the continuum. Irrespective of the congressional debate about the Patient Protection and Affordable Care Act (PPACA), significant reform of care delivery and payment systems is on its way.

While the specifics may still lack clarity and the implementation timetable may be uneven, the agenda for change is being implemented and hospital leaders will sooner rather than later begin their repositioning initiatives, because the new marketplace requires a fundamental redefinition of the hospital success model.  

One of those initiatives has shone a spotlight on hospital case management departments. To determine how hospitals can be successful in the future, the executive team recognizes that it has to address the concerns that have surfaced during the move to value-based care. And many of those concerns relate to coordinating care for selected patient populations across the continuum. They will quickly realize that a total transformation of their traditional case management assumptions is essential to thrive in the new marketplace. 

Care coordination has always been a component of case management, but there are not many hospital case management departments that have the luxury of a care coordination mandate. Over the years, more and more tasks were added to the case manager role until care coordination, while always on the minds of many case managers, took a back seat to planning and arranging discharges, reviewing charts for utilization review, and performing scores of chores that surfaced to meet hospital, regulatory, or medical staff needs. Role expectations became overwhelming and led to frequent vacancies and difficulties recruiting replacements willing to take on such overburdened roles.   

Visionary leadership helps turn a good organization into a great organization. Executive suite leadership sets the culture, tone, and expectations of quality, safety, and cost-effectiveness – but it is the program leader who must rethink the future. This is the individual most influential in transforming a legacy, task-oriented case management department into a hospital-wide care coordination program.  It is a daunting responsibility, with many moving parts involving the medical staff, business operations, and patient care. This is not the time to dig your heels in to maintain the status quo; this is the time to explore new horizons and new goals, and to give dynamic meaning to the work we are supposed to do as case managers.

Care coordination is not a department. It is, or should be, a core competency of every organization, involving every care team member and business associate. Leadership must make sure every hospital associate understands the vision of care coordination and what role they play in achieving it. Care coordination is an enterprise-wide program, and every employee should know what they need to do to bring the vision of care coordination to life.   

This means setting audacious goals and enlisting colleagues and champions to help achieve them. It means restructuring and reorienting the resources hidden in various service lines and deploying them more effectively across the continuum. It means evaluating all non-value activities currently assigned to the case management “department’ and finding the right home for them.  And it means that everyone is responsible to identify barriers and problems to efficient progression of care, to question the purpose of low-value medical interventions, and to experiment with options that will promote and hardwire teamwork.  

Care is being delivered in more settings than ever before. The walls of your hospital no longer define the limits of care coordination responsibilities. Hospital leaders are cautiously experimenting with risk-based payment extending beyond hospital boundaries, and hospitalists are doing the same with multidisciplinary teamwork while exploring the benefits of regionalized care.

Multidisciplinary care teams are widely regarded as the most effective structure for improving care for defined populations. I have seen a variety of approaches to care teams, some with fewer staff and some with more. When fewer are involved, coordination often suffered. I have found that all care experts are needed at the table to efficiently address the many questions and concerns that surface at team meetings. High-quality care coordination is built on a collaborative, multidisciplinary, and highly communicative care team working on behalf of the patient and family, which, in addition to instilling greater hospitalist efficiency, seems to be the motivating force behind accountable care units.  

At a time when hospital leaders are carefully reviewing all aspects of operations to determine ways to reduce costs and increase efficiency, care coordination activities play an important role in managing resource utilization and costs per patient day. By working closely with high-risk patients and their families, along with the physician and the care team, care managers play a critical role in ensuring that patients receive the right care in the right setting. They are best positioned to encourage the use of evidence-based guidelines, to promote concise documentation at the point of care, and to question the use of wasteful, excessive, or potentially harmful interventions.

The care managers must exercise their advocacy role to keep safety, quality, and cost-efficient care on the minds of each member of the care team. 

Program Note:

Listen to Stefani Daniels live this morning on Talk Ten Tuesday as she reports this important story.