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C H A P T E R
8
 Instituting Bedside Case Management

          Bedside case management is instituted in acute care facilities for numerous reasons including to:

·     Improve continuity and quality of patient care.

·     Increase patient and patient support person(s) participation in care as well as their satisfaction with care.

·     Improve patient and patient support person(s) education.

·     Promote a collaborative practice approach to patient care.

·     Decrease fragmentation of health care services.

·     Increase nursing, physician, and all other health care discipline satisfaction.

·     Increase physician and staff education.

·     Provide for efficient use of resources.

·     Improve communication, collaboration, and coordination within and across all of the health care disciplines.

·     Enforce appropriate length of patient hospitalizations by defining expected patient outcomes and timely patient care interventions.
(Smith et al, 1994; Smith & Wolf, 1997)

          There are several steps involved in the planning process before bedside case management can actually be instituted. The first step is assessing the costs for the care provided to high volume, high cost, high resource usage diagnosis related groups (DRGs) (Stiller & Brown, 1996). The assessment should begin with looking at the average cost for providing care for a DRG and comparing that average cost to cost variances which are a result of variable practice methods (IBID). This data will help to identify cost reductions that occur as a result of standardized practice. “Each DRG is viewed as a service line and is broken down into various needs and financial components: acute care services required, LOS (length of stay) and anticipated charges as they accrue, desired treatment and educational outcomes for each day of acute-care hospitalization, medical discharge criteria, and related hospital or community resources appropriate for that particular service line” (Bair et al, 1989). One element that needs to be assessed is the availability of information systems for financial data collection and analysis. It is important to identify what systems/reports will be used for collecting information for the selection of the DRG that bedside case management will be instituted for i.e. the hospital billing system or multi-disciplinary meetings in which case types are discussed and who has access to this information.

          When discussing case types, some questions that need to be asked to gather the necessary information with regard to what DRGs need bedside case management include:

·     What case types are high volume or use a high number of health care resources?

·     What is the average time the identified case types are hospitalized for?

·     What are the problems associated with the identified case types, and what are realistic timeframes for resolving these problems?

·     What problem-related outcomes can be expected to be met during and at the end of the patient’s hospitalization?

·     What actions are required of the health care team to move the patient toward and beyond discharge?

          Since it is not always a hospital’s governing body that decides the patient care delivery system needs to change, the second step in the bedside case management institution planning process is obtaining the support of hospital administration. Before any change in the way patient care is delivered can be instituted, the powers-that-be have to give their approval. At this point, the financial information collected in the first step along with any literature to support the change should be presented (Stiller & Brown, 1996). “It is important to include information that will minimize fear and resistance to change” (IBID). Along with furnishing the financial data and the information collected in the literature search to administration, the strengths and weaknesses of the current patient care delivery system need to be assessed and presented as groundwork for establishing how bedside case management would further enhance patient care delivery strengths while decreasing weaknesses. The hospital’s administration would also need to know how a bedside case management patient care delivery model would fit into the current hospital environment and how difficult the transition to this type of patient care delivery might be. According to Cohen and Cesta (1994), “The case manager at the bedside must have the support of administration in order to effect changes in cost and length of stay necessary to make the case management approach successful”. Along with soliciting the support of hospital administration, the hospital’s organizational structure and pathways of communication need to be looked at to see what changes are needed to effectively clear the way for the institution of bedside case management. Once hospital administration’s support is gained, the endorsement of all department managers must be sought. It is important to gain the department managers’ support as the next step in the planning process is forming a multi-disciplinary task force to look at all that is involved when instituting bedside case management. It would be difficult to recruit the multi-disciplinary task force members without the department managers’ approval. Once administrative and management approval for the multi-disciplinary task force has been granted, the recruitment of task force members can commence.

          The overall goal of the beside case management institution task force is to examine what it would take to establish a bedside case management patient care delivery model within the hospital. The chairperson of the task force should be someone who has knowledge of bedside case management, has excellent communication skills, and has reputable clinical expertise (Stiller & Brown, 1996). The task force should include representatives from all disciplines involved in rendering health care services including, but not limited to: nursing, medical staff, social services, nutrition services, pharmacy, laboratory, rehabilitation services, radiology, and respiratory therapy (IBID). According to Stiller and Brown (1996), “Functions to be delegated to this group include:

1.  Site visits to institutions with experience in case management and other care delivery models.

2.  Developing the recommendation for employing, or appointing, an individual to direct the case management program.

3.  Identifying individuals who can develop standardized CareMaps and select cases to be managed.

4.  Developing an implementation timetable.

5.  Developing evaluation mechanisms to monitor the program’s efficacy.

6.  Conduction of a literature search”.

          The information from the literature search collected by the task force should be shared among all of the health care disciplines involved in patient care so that each discipline can examine its possible role with regard to bedside case management (IBID). Looking for alternative models for patient care delivery is an ever-evolving process, and all health care disciplines should be involved with recognizing opportunities for changes in clinical practice (Walrath et al, 1996).

          After the literature search is complete and the task force members have had a chance to contemplate bedside case management theory and to conduct the groundwork necessary for transitioning into a bedside case management patient care delivery model, it is time to get the physicians involved so that group practices can begin to form. Some points to ponder before approaching the physicians are:

1.  Is there currently any collaborative practice established between nurses and physicians?

2.  Do nurses and physicians currently serve together on shared committees?

3.  What physicians are foreseen as potential supporters of a bedside case management model for patient care delivery?

          If there is collaborative practice between nurses and physicians already established, even to the smallest degree, and if this collaborative practice is viewed positively by both the nurses and the physicians, some of the groundwork for winning the physicians over to bedside case management may be already laid. If nurses and physicians currently serve together on shared committees, and if it is a positive experience for both the nurses and the physicians, these joint committees are a good place to look for physician support of bedside case management. The physicians who can be identified as likely supporters of a bedside case management patient care delivery model should be approached first with the concept and then employed to assist with presenting it to the rest of the medical staff. Ways to encourage physician involvement include:

·

Putting together folders that contain bedside case management information with findings from the literature search highlighted, and placing the folders where physicians will have time to look at them such as in the hospital library or the physician lounge.
 

 
·

Sponsoring a luncheon or a dinner with the guest speaker being a physician who has had experience with a bedside case management or collaborative practice approach to patient care delivery and, along with providing lunch or dinner, issuing continuing medical education units for the guest speaker’s content.
 

 
·

Getting hospital administration involved in interfacing with the physicians and presenting to them how bedside case management can improve patient care as well as assist with decreasing physician workload.
 

 
·

Encouraging nurses who have good communication patterns established with physicians to share the benefits of bedside case management with them. (Stiller & Brown, 1996).

          According to research by Stiller and Brown (1996), “Physician support is critical to the success of any changes in the care delivery system… Failure to include physicians in the initial planning process, through which support for providing quality outcomes is realized, was reported by experienced case managers to result in implementation delays, and in some instances, program failure”.

          After the physicians become involved in the decision making process, it is time to determine the qualifications and skills needed by the bedside case manager as well as the responsibilities that will be a part of the bedside case manager role. Responsibilities that the bedside case manager will be held accountable for may include:

· Initiating the use of the critical pathway that is appropriate for the patient’s diagnosis.
   
· Monitoring patient progress along the critical pathway.
   
· Documenting any variances from the critical pathway standards.
   
· Taking appropriate actions to rectify any variance.
   
· Making needed referrals and following up to make sure appropriate consultations have been made.
   
·

Formulating a discharge plan and making sure that it is followed. (Johnson & Proffitt, 1995) 

Nugent (1992) notes, “the successful application of the integration of case management and collaborative practice depends upon the person who assumes the pivotal role of case manager”.

          Before instituting a bedside case management patient care delivery model, it is necessary to conduct an assessment of the nursing staff’s clinical competence with regard to managing patient care. Competent patient care management is paramount to the success of the bedside case management program, as it is the principal function of the bedside case manager role. The registered nurse who takes on the bedside case manager role needs to possess the ability to make appropriate and timely patient care decisions and also needs to be proficient at planning and coordinating patient care. The bedside case manager will have to go through a transition from traditionally viewing the patient’s hospitalization as just an episode of illness to seeing the patient’s whole health care picture, including wellness strategies that need to be employed to keep the patient relapse-free (Conger, 1998).

          The goals the bedside case manager needs to keep in mind while coordinating patient care include: betterment of patient and physician satisfaction, a decrease in the patient’s length of stay, enhancement of the patient’s comfort level and improvement of patient outcomes as well as quality maintenance and cost containment (Bayard et al, 1997).

          While many of the responsibilities of the bedside case manager role are functions many nurses have previously carried out, bedside case management does include some new duties that the bedside case manager will have to learn. The bedside case manager is not the only health care discipline that will need education. All of the health care disciplines involved in patient care, including the physicians, will also need instruction with respect to the principles and application of bedside case management.

          To begin the education process, a bedside case management institution task force member needs to become expert with regard to bedside case management principles and their application (Stiller & Brown, 1996). This expert would then in turn educate all non-physician health care disciplines about bedside case management. However, before any teaching is begun and to establish a starting point for the education process, the expert should first assess how much the staff to be taught already knows about bedside case management. Once this knowledge assessment is complete, the expert can start planning the curriculum for the training sessions. In addition to bedside case management principles and application, it will be important for the expert to provide financial and management skills training for the nurses who will be in the bedside case manager role. The nurses who take on the bedside case manager role will need to know how to:

· Manage patient care costs.
   
· Work with third party payers.
   
· Utilize health care resources and services effectively.
   
· Decipher insurance plan and Medicare coverage.
   
· Handle diagnosis related groups (DRGs).
   
· Make autonomous, informed decisions.
·   Problem solve effectively.
   
· Formulate discharge plans.
 
·  Guide the patient toward the expected clinical outcomes and evaluate those outcomes.
   
· Recognize variances and formulate action plans to offset them.
   
· Work within a group practice model of patient care.
   
· Coordinate patient care services.
   
· Delegate patient care tasks appropriately.
   
· Supervise patient care activities.
   
· Communicate well with physicians.
   
· Collaborate effectively with other health care disciplines in the care of the patient.
   
· Perform telephone assessments and follow-ups.
   
· Carry out concurrent chart reviews.
   
· Manage time effectively.
   
· Do thorough assessments of the patient and the patient’s support person(s).
   
· Include the patient and the patient’s support person(s) in the planning, implementation, and evaluation of patient care.
   
· Effectively confer educational information to the patient and the patient’s support person(s).

          According to Anderson-Loftin et al (1995), when it comes to educating the physicians about bedside case management the “…ideas must be clearly and concisely presented by a knowledgeable individual who seeks and uses their input, and implementation of the ideas cannot place unrealistic demands on their time” (p. 35). Because the physicians may feel threatened about nurses participating in their decision making process and may believe that bedside case management will be an infringement on their practice, Stiller and Brown (1996) recommend that “Physicians should be provided an outside consultant, preferably a physician with experience in managed care. This provides a mechanism for reducing any lingering perceptions that case management impinges upon the decision-making role of the physician”.

          The next step in the bedside case management institution process is selecting the types of cases to begin managing. This selection process should begin by taking a look at the hospital’s average patient population and exploring case types, payer mix, average lengths of stay, and common DRGs. The case types that require higher health care resource use, that are high volume, that are high cost, that the hospital receives inadequate reimbursement for, or that have longer lengths of stay are examples of case types that should be the initial focus for the institution of bedside case management. According to Stiller and Brown (1996), those involved in case type selection must take both cost factors and the delivery of quality care into careful consideration as “case selection is as important as developing the plan of care or critical pathway”. Stiller and Brown (1996) site Wagie’s and Kraushar’s (1994) nine-step process for case type selection as follows:

1.  “Make friends with someone in medical records and the finance office.
   
2.  Determine the capabilities of the institution’s cost accounting system to provide information related to cost per DRG. If sophisticated systems are not in place, collaborate with the DRG coding staff to obtain reports and statistics on the information you need.
   
3.  Construct Pareto charts (bar graphs) for the top 10 DRGs that fit into categories of high volume, high charges, low reimbursement, and those diagnoses consuming the most time in the risk management department.
   
4.  Compare each DRG by frequency, charge, and reimbursement.
   
5.  Note which DRGs are in the top third of each Pareto chart.
   
6.  Using the Pareto charts, determine the highest financial loss DRGs.
   
7.  Determine which DRGs are of most interest to the staff, and which are the most predictable.
   
8.  Determine the high-risk DRGs. Keep in mind the fact that the highest risk DRGs may not be included on your list because of their unpredictability based upon factors such as pre-existing.
   co-morbidity or erratic response to treatment. Go for success by selecting predictable DRGs first, then tackle these harder cases.
9.    
10.  Present the findings to the multidisciplinary group to decide which, and how many, DRGs to develop critical paths for”.

Once the case types to be managed are selected, the bedside case management institution task force members can develop the critical pathways as outlined in Chapter 6.

          After bedside case management has been instituted, its effectiveness must be evaluated. The process for evaluating bedside case management must be developed during the planning phase. Perhaps, during the bedside case management planning phase, a sub-committee of the bedside case management institution task force could be designated as responsible for carrying out the evaluation process. To fully evaluate how well the bedside case management patient care delivery model is working, it is necessary to compare data on the length of hospitalization, the health care service costs, and the re-admission rate for the types of cases being case managed from both before and after bedside case management was instituted (Stiller & Brown, 1996). According to Stiller and Brown (1996), data for such comparisons can be found in the following places:

·

The medical records department can usually furnish the length of hospitalization data.
 

 
·

The finance department can generally provide the costs for health care services rendered.
 

 
·

Collection and evaluation of information from the medical records of specific case types, both pre and post bedside case management institution, will reveal re-admission rates.

          Variances from the critical pathways will need to be investigated during the post bedside case management institution evaluation phase. The reasons for the variances as well as whom or what was responsible for them will also need to be examined. In addition, the evolving role of the bedside case manager and the nurses’ satisfaction with all that the role requires, will need to be taken into account during the post bedside case management institution evaluation phase. Along with surveying the nurses’ satisfaction with the new model of patient care delivery, the satisfaction of the physician(s), the administration, the managers, the other health care disciplines, the patient care team and, most importantly, the patient and the patient’s support person(s) needs to be assessed as well. Once everyone’s feedback is received and all data has been evaluated, any necessary changes to the bedside case management model can be implemented.

Summary

          The institution of a bedside case management patient care delivery model demands that the hospital change its current patient care delivery system. With change comes fear and apprehension from all health care arenas of the hospital including not only the staff members who will be providing direct patient care but from hospital administration, management, and the physicians as well. To combat this alarm and anxiety, the multi-disciplinary bedside case management institution task force must become well versed in bedside case management theory and must select an expert among them to educate hospital administration, management, staff members, and physicians about the benefits of bedside case management. To further support the transition to bedside case management, it would be beneficial to have a peer physician, who has had experience with a bedside case management patient care delivery model, interface with the physicians on staff. For bedside case management to be successful, everyone in the hospital has to be committed to its principles and be willing to apply those principles to clinical practice.

REFERENCES

Anderson-Loftin, W., Wood, D., Whitfield, L. (1995). A case study of nursing case management in a rural hospital. Nursing Administrator Quarterly, 19(3), 33-40.

Bair, N., Griswold, J., Head, J. (1989). Clinical RN involvement in bedside-centered case management. Nursing Economics, 7(3), 150-154.

Bayard, J., Calianno, C., Mee, C. (1997). Care coordinator – blending roles to improve patient outcomes. Nursing Management, 28(8), 49-51.

Cohen, E., Cesta, T. (1994). Case management in the acute care setting a model for health care reform. Journal of Case Management, 3(3), 110-115.

Conger, M. (1998). Integration of acute care CNS and case manager roles. Critical Care Nursing Clinics of North America, 10(1), 127-134.

Johnson, K., Proffitt, N. (1995). A decentralized model for case management. Nursing Economics, 13(3), 142-151.

Nugent, K. (1992). The clinical nurse specialist as case manager in a collaborative practice model: Bridging the gap between quality and cost of care. Clinical Nurse Specialist, 6(2), 106-111.

Smith, G., Danforth, D., Owens, P. (1994). Role restructuring: Nurse, case manager, and educator. Nursing Administration Quarterly, 19(1), 21-32.

Smith, G., Wolf, D. (1997). Orientation program for a hospital-based dual case manager and educator role. Journal of Nursing Staff Development, 13(2), 77-82.

Stiller, A., Brown, H. 91996). Case management: Implementing the vision. Nursing Economics, 14(1), 9-13.

Walrath, J., Owens, S., Dziwulski, E. (1996). Case management – a vital link to performance improvement. Nursing Economics, 14(2), 117-122.