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 II

Marcia Colone, Ph.D., LCSW, ACM, Steven McGaffigan, LCSW, ACM, Cindy Beemsterboer, RN, ACM, Sue Johanson, RN, MS

In Part I of this article series (Winter, 2006), the experience with a pilot project of the care facilitator role on a neuroscience unit was described.
The outcomes of that trial exceeded expectations and based on that success, administration authorized the expansion of the new care
coordination model throughout the adult medical/surgical population. This article shares the experience of implementing that expansion and
lessons learned along the way.

THE EXPANSION Challenges created by the service-based structure include:

The expansion of the care coordination model was led by the
newly created RN care facilitator role and began on the Medicine
Services in October. The Oncology and Surgery Services followed in
February and April, respectively. The first
step in the expansion process was to
develop the implementation and staffing
plan, which assigned FTEs to the roles of
RN care facilitator, continuity of care RN
coordinator (COC) and social worker.
Secondly, a work plan was developed
describing critical elements such as
communication, recruitment,
orientation, launch dates, and outcomes
reporting. Outcomes measured by the
metrics of LOS reduction and avoidable
days were supplemented with: patient
satisfaction, discharge by time of day, and
physician satisfaction.
The pilot experience had highlighted
the importance of face-to-face
communication regarding the new
model. Special attention was given to the
communication plan in this broader
roll-out. Meetings to describe the model,
the background of its development and
• The service-based organization of care facilitators favors the
physician who communicates with only one care facilitator.
• The care facilitator may have patients on
5 to 11 units, which creates navigation,
time and communication challenges
when some of those units are inevitably
geographically disbursed.
Outcomes measured • Significant time is devoted to producing
and updating an accurate patient list for
by the metrics of nursing units and to other departments
such as rehabilitation services.
LOS reduction and • Timely update to case management and
unit staff members is difficult due to
logistical challenges. The COC or social
avoidable days were worker often encounter a physician on
the unit and learn about the plan of care
supplemented with: before the care facilitator.
• Care facilitators are less visible to a single
patient satisfaction, unit-based health care team, which
negatively impacts relationship building.
discharge by time • Staff ratios for the care facilitators necessitate
that they retain the utilization review
of day, and physician responsibilities for Medicare patients.

to discuss expectations were held with

physicians, nursing, rehabilitation services, satisfaction.
ancillary and diagnostic services. The
understanding and acceptance of the new
case management model was a critical
aspect of its success.
LESSON 1: THE STRUCTURE IS IMPORTANT
Despite the success of the pilot, the consensus of decision-
makers was to shift from a unit-based approach in favor of one that
is service-based. The General Medicine Service encompasses
eight different nursing units and 192 beds, while Oncology is
comprised of three units with a total of 83 beds. In General Medicine,
approximately one third of patients are managed by Hospitalists, and
two thirds by the resident service. Eight care facilitator positions were
approved to cover all 275 patients yielding average caseloads of 1:34.
These high caseloads and a number of other challenges identified
below restrict the amount of time the care facilitator can proactively
advance the plan of care.
3
LESSON 2:
MANAGE PHYSICIAN EXPECTATIONS
It has been particularly satisfying to see
the organization develop a culture of
accountability to improve care
coordination and communication, and
reducing “hand-offs.” The response to the model by various
constituencies has been one of collaborative support. For example,
most recognize the need for an enhanced care coordination process
and are receptive to avoidable day reports that suggest opportunities to
support hospital-wide efforts to enhance bed capacity.
Physicians are engaged in the new model, but it is with this group
that we see the greatest variability in response to implementation.
Physicians prefer to see the care facilitator be more available to meet
their specific needs such as retrieving medical records, reviewing
discharge instructions, setting up outpatient appointments, and other
duties of a “physician extender.” Setting clear expectations of what the
new care facilitator’s role is and is not will aid acceptance and
appropriate utilization of the new role.
(continued on page 8)
 C O L L A B O R A T I V E
Advancing Case Management Practice – Part II (continued from page 3)
Physicians are less apt to defer to care facilitator judgments about
what is or is not an avoidable day. Therefore, the data collection
processes incorporate a narrative account for each avoidable day
identified and categorized in our database. These case-by-case
accounts serve to establish case management credibility and serve as
the basis for educating those that receive the reports.
LESSON 3: RECRUITMENT PROCESS
AND RESULTS INFLUENCE TEAM BUILDING
The position of care facilitator was reviewed by the Compensation
and Benefits staff and placed in an administrative pay grade rather
than the nursing salary program. This means care facilitators are not
eligible for periodic market salary adjustments to pay. An internal
recruitment process to fill the new positions would take place prior to
initiating external recruitment. Staff members were assured that their
current jobs were not in jeopardy. Even so, the recruitment process
posed some challenges:
• Staff members had to assess their own level of interest in applying
for the RN care facilitator role. Not all were professionally prepared
to meet the new expectations of the position.
• There was anxiety about how the existing roles would change in
the new model.
• The care facilitator position is specifically an RN position. This
excluded social workers from a promotion opportunity.
The department was under significant pressure to implement this
new program quickly by adhering to an aggressive work plan and
achieving outcomes similar to the pilot. As a result, the interview
process had to be initiated quickly. The job description was finalized
and list of interview questions were developed and made available to
all staff members. Central to the care facilitator role are qualities and
skills, which include leadership, collaborative problem solving and the
ability to coach. Moreover, potential candidates needed to discuss their
ability to thrive in ambiguous and complex situations.
Of great concern to department leadership was our desire
to deal sensitively with staff members who were not selected. Only
fifty percent of the existing eligible RN staff applied. Human Resources
staff was consulted and the message to applicants was that the
hiring decision revolved around the degree of a candidate’s
advancement readiness. Those who were determined not ready for
promotion were offered the opportunity to work with their managers
to create a development plan tailored to their particular need(s) for
leadership experiences, or to their training needs related to technical
skill and proficiency.
It was anticipated that some nurses might consider other
opportunities as a result of the significant change in the department. In
fact, four nurses terminated voluntarily, placing added stress on the
implementation plan. Agency nurses were hired to assure that the
Resource Center could manage the volume of reviews, as well as the
complexity of navigating through multiple information systems that
were not connected and required manual manipulation.
External recruitment continues with the goal to achieve the right
balance of new and seasoned staff members. Continual coaching is a
C A S E M A N A G E M E N T
requirement for both the care facilitators and existing staff members.
Weekly seminars are held for the care facilitators. At these seminars,
issues are raised, experiences are shared, and data are reviewed.
Mutual learning occurs and feedback, both group and individual, is
given routinely. Prior to hiring a new care facilitator, candidates are
evaluated on their tolerance for feedback.
LESSON 4: LEADERSHIP OPPORTUNITIES ABOUND
THROUGHOUT THE PROCESS
Challenging situations that involve changing the case management
model stir strong emotions among stakeholders. What is critical in such
situations is to maintain an objective viewpoint and remain open to
understanding the issues and perceptions of the stakeholders.
Participation in all discussions about the benefits, issues and challenges
in changing the case management model is essential. This requires
patience, perseverance and the willingness to manage assumptions or
recommendations that are incorrect, misleading and reflect a lack of
understanding of contemporary case management practice.
Many opportunities will be available to take the lead in presenting
information and data that will clarify the issues under discussion.
Maintaining a focus on the facts, the needs of the patients, and the
most effective delivery of case management services will keep the
discussion objective.
Questions about the efficacy of the case management model
represent opportunities to advance case management practice.
Regardless of the current model that is used, there are always
opportunities to make improvements in practice, processes and
communication. Case management is an ever-changing practice that
remains relevant by its ability to adapt to new organizational goals and
pressures. Starting from the premise that change is positive will
strengthen the process with stakeholders.
LESSON 5: DATA ARE THE ENGINE OF CHANGE
Without data, observations, anecdotal information and
experiences reign. Data demonstrates the added value that case
management practice contributes to the organization’s goals.
Evaluating available data will help assess the efficacy of case
management practice and opportunity for improvement or change.
The willingness to use data to engage in the evaluation of the delivery
of case management services supports the image that case
management is a data-driven practice. Observations and
recommendations supported by data are invariably received well.
Ongoing evaluation of the outcomes metrics for case management
is essential to evaluate the success of the implementation but also to
measure the impact of the new model of case management. If the
improvements expected in the outcome metrics (identified earlier as
indicators of success for this expansion) are not realized, re-evaluation of
the model would be necessary.
These lessons have proven valuable as the expansion continues
and is refined. As well, they are important lessons in leadership of
change that will prove valuable as the practice of case management
continues its inevitable evolution to meet the dynamic needs of
patients in the ever-changing healthcare environment.