September 24, 2020

Case Study: Redesigning the Inpatient Case Management Team

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How reevaluating the structure of the hospital's discharge planning arm is better supporting complex patients and staff

The discharge planning arm of a patient’s hospital journey primarily lies with the patient’s case manager, a nurse who helps evaluate the patient’s discharge needs and collaborates on the best plan for the patient after discharge. The process for most patients is straightforward: they either go to another facility or gain some temporary support at home and connect with outpatient clinics.

At Boston Medical Center (BMC), however, the discharge planning process is complicated by its complex patient population, who may not have insurance, citizenship, or homes to discharge to. Delays in creating a safe discharge plan can result in unnecessary days in the hospital even after patients are medically cleared for discharge, resulting in unnecessary costs to our healthcare system, unavailable beds for those who need them, and frustration across staff.

Finding solutions to appropriately reduce length of stay and facilitate better throughput is top of mind for clinical operations — at BMC, our average morning occupancy was 98% on our Medical Surgical floors, for example, versus an industry target of just 80%. Further, every week, we identified at least 30–40 patients “stuck” in the hospital. Freeing these beds and back-filling them with new patients creates a significant financial opportunity associated with reducing length of stay.

The hospital’s Central Flow Unit (a team of physician, nursing, and administrative leaders that oversee and improve patient flow) partnered with our case management department to evaluate opportunities to support the team given the complexity of our patient population. We examined three core questions in consultation with other hospitals.

Should our case managers be responsible for discharge planning and utilization management, or split the tasks?

Case management departments typically support both the discharge planning process and the utilization management function, which ensures appropriate payor reimbursement given the clinical profile of the patient. In different environments, case managers do both tasks or divide the responsibilities over two groups.

Is a team-based, unit-based, or hybrid case management model most appropriate for our hospital’s needs?

Case management can be structured to follow either a set number of beds (e.g., beds 1 – 20 on a unit) or a physician team (e.g., general medicine team). Both models have pros and cons that need to be assessed for each environment. Whereas some hospitals localize physician teams to specific units, this alignment was not the case at Boston Medical Center.

What is the appropriate number of patients for a case manager to support?

Based on the design of the unit vs. team-based alignment, and the inclusion or exclusion of utilization management, a hospital must determine how many patients a case manager can effectively support.

As a result, we designed a new discharge planning structure that has shown early success in reducing length of stay.

Context: What drove the redesign

We historically followed a unit-based structure where each case manager followed a set of beds — a maximum of 18 beds on a Medical Surgical unit — which facilitated strong relationships with patients’ families and other unit-based teams such as nursing. In this model, case managers were responsible for both the discharge planning and utilization management process.

Our physician teams were scattered across many units, increasing the number of case managers each physician team had to interact with, and likewise the number of physician teams each case manager had to interact with. In fact, a review of our data showed that our highest-volume teams were interacting with eight to nine case managers on average. This model created huge inefficiencies, and as they interacted with more case managers, patient length of stay also increased.

Balancing discharge planning and utilization management

After evaluating our systems, we chose a hybrid case management model — pairing the physician teams that were the most scattered with a team-based case manager, and assigning specific beds for the other case managers. This model requires more day-to-day management from leadership to distribute patients among case managers, but provides relief to the physician teams and case managers who were struggling with a high number of interactions.

Pre-COVID, we had settled on keeping the discharge planning and utilization management tasks associated with patients to one case manager. This was our incumbent model. It had synergies across the tasks, and it was also a team structure supported by half the institutions we consulted.

However, COVID-19 response necessitated that our case management department internally split the tasks. A central team managing denials and appeals took on the utilization management tasks for all patients in house, benefiting from the fact that we primarily cared for one diagnosis: COVID-19.

Anecdotally, our floor case managers appreciated the bandwidth to focus on discharge planning afforded by the split of responsibilities. We are now striving to maintain this split given the staff satisfaction.

Appropriate case mangement case load

Our final question concerned how many patients per case manager was appropriate to facilitate efficient and high-quality throughput. Our inquiry into the caseloads per case manager at other institutions quickly highlighted that our case managers were caring for significantly more patients — an average of 17 patients at BMC while the average at other hospitals was 12, accounting for differences in structures.

In the end, with the shift to team-based case management we reduced the case load for the case managers assigned to these teams, accounting for the fact that they will be spread out, an additional challenge in its own right. We maintained the case load for the other case managers, appreciating that they now could focus on discharge planning exclusively, bringing their case load on par with other institutions who have split functions.

Conclusions from case management redesign

Our decisions related to the structure of case management were anchored in additional recommendations meant to strengthen the processes and data systems within the department to make the environment that our case managers work in effective for them. Underscoring these efforts is collaboration across disciplines and strong, on-the-ground leadership ensuring these changes work for the front-line teams. We are assessing the impact of these changes with both qualitative and quantitative metrics and are excited for the potential these changes have for our patients and our staff — initial findings of 0.7 day reduction in LOS for teams in this new program compared to a baseline of five months indicate we are on the right path.

Boston Medical Center is a 514-bed hospital and houses the busiest emergency department in New England. In January 2019, we created the Central Flow Unit (CFU) which oversees patient flow and is co-led by physician, nursing and administrative leaders. The CFU, in collaboration with many stakeholders, has worked to improve patient flow and problems many hospitals encounter. Along the way, we have turned to the literature and our peers across the country to learn more about the challenges and progress against them. In the spirit of collaborating across institutions, we are sharing an inside look at some of our biggest successes in improving inpatient operations and care. Don’t forget to check out our other results in The Hospital Playbook series.

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About the Author

Neha Gaur

Neha Gaur is the senior director of inpatient operations and cancer care at Boston Medical Center. She co-leads the Central Flow Unit with nursing and physician partners. She graduated from the University of Pennsylvania and the Wharto...

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