An Evidence-Based Approach to Case Management Model Selection for an Acute Care Facility

Optimization of Patient Progression in a New Era: A Comprehensive Framework

PURPOSE/OBJECTIVES

The onset of the coronavirus disease 2019 pandemic increased the demand for inpatient services and led to widespread staffing shortages in the acute and post-acute setting, contributing to delayed inpatient throughput and leading to capacity crises. Novel strategies are needed to facilitate the efficient progression of hospitalized patients when medically ready for lower levels of care. The authors have developed a foundational strategic framework for patient progression to ensure capture of patient progression data, enhance efficiency, and optimal utilization of post-acute resources in increasingly complex and resource-constrained acute and post-acute environments.

PRIMARY PRACTICE SETTINGS

Interventions were implemented, and metrics of success tracked as part of an overarching framework to test new models of care or optimize existing assets related to barriers to patient progression. Brigham and Women's Hospital (BWH) and Brigham and Women's Faulkner Hospital (BWFH) comprise an academic medical center and a community hospital, respectively, that are affiliated with Massachusetts General Brigham (MGB), a nonprofit health care system in Massachusetts. Key interventions include (1) screening to prioritize patients needing case management services through a modified early screening for discharge planning tool and process; (2) communicating, documenting, identifying patient progression status, barriers to discharge and post-acute needs through interdisciplinary care optimization rounds, a novel tool in the electronic health record, and an associated dashboard; (3) managing active high-risk patients through a novel complex care team and post-acute strategy development; (4) developing novel transportation and hospice pathways; and (5) establishing community hospital repatriation and a physical therapy "Why Not Home" campaign.

FINDINGS

Key metrics of success were (1) modified discharge planning tool resulting in screening out low-risk patients (53%) and impacting length of stay (0.55-day reduction, p = .083) during a 3-month intervention versus control study; (2) documentation adherence in more than 98% of patients 10 months postimplementation; (3) complex care team achieving a 2.5% reduction in Case Mix Index-adjusted length of stay 6 months postimplementation; (4) use of care van offsetting ambulance/chair car in 10% of cases, and earlier discharge time/length of stay in 21% of cases 3 months postimplementation; and (5) implementation of community repatriation impacting delay days to discharge (10-month pilot, 40 patients accounting for 1,000 delay days).

CONCLUSIONS

Implementation of a novel comprehensive framework focusing on optimizing patient progression resulted in increased operational efficiency and positively impacted length of stay at our academic and community hospitals. Additional study is actively ongoing to understand long-term benefit of the innovations that the authors have developed. Further interventions are needed to wholly mitigate evolving capacity challenges in the acute and post-acute settings.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The authors' implementation of the Brigham framework for progression demonstrates that innovative approaches to case management can help address the evolving challenges in care transitions planning. Notable opportunities include approaches that empower case managers as multidisciplinary team leaders, improve workflow, utilize patient progression data, prioritize patients with complex care needs support key patient populations, and promote post-acute collaboration.

Experiences of nurse case managers within a central discharge planning role of collaboration between physicians, patients and other healthcare professionals: A sociocultural qualitative study

AIMS AND OBJECTIVES

To gain knowledge of nurse case managers' experiences within the German acute care context of collaboration with patients and physicians in a discharge planning role; further to learn about patients' assignment to the management of the nurse case managers; and explicitly to explore critical incidences of interactions between nurse case managers, patients and healthcare practitioner in discharge planning to understand the factor that contributes to effective collaboration.

BACKGROUND AND PURPOSE

The defined role of nurse case managers in many contexts is a patient-centred responsibility for a central task of discharge management of patients with complex physical and social needs. Some studies have indicated that the general impact of the role reduces readmission rates. Given the necessity to work interprofessionally to achieve a safe discharge, little is known about how nurse case managers achieve this collaboratively.

METHODS

A qualitative case study within a German teaching hospital of nurse case managers (N = 8). Data were collected through semi-structured interviews prompted by a critical incident technique and rigorously analysed through the lenses of sociocultural theory.

RESULTS

Consistent object being worked upon was a safe and effective discharge from hospital with a focus on patient advocacy. Significant themes were a self-value or recognition by others of professional expertise, reciprocal value on the capabilities of others thorough relational expertise and negotiation with patients and an identification of case trajectories.

CONCLUSION

More continuity of nurse case managers' care and management, clarity of role and transparency to peers, physicians and other professionals would be beneficial in ensuring appropriate referral of complex patients to nurse case managers responsibility.

RELEVANCE TO CLINICAL PRACTICE

Clearer role description and benefit realisation of the nurse case managers could be achieved by interventions that are interprofessional and focus on the tasks that matter from a collaborative perspective. This could lead to refinement of available indicators and policy developments.

Prediction of length of ICU stay using data-mining techniques: an example of old critically Ill postoperative gastric cancer patients

OBJECTIVE

With the background of aging population in China and advances in clinical medicine, the amount of operations on old patients increases correspondingly, which imposes increasing challenges to critical care medicine and geriatrics. The study was designed to describe information on the length of ICU stay from a single institution experience of old critically ill gastric cancer patients after surgery and the framework of incorporating data-mining techniques into the prediction.

METHODS

A retrospective design was adopted to collect the consecutive data about patients aged 60 or over with a gastric cancer diagnosis after surgery in an adult intensive care unit in a medical university hospital in Shenyang, China, from January 2010 to March 2011. Characteristics of patients and the length their ICU stay were gathered for analysis by univariate and multivariate Cox regression to examine the relationship with potential candidate factors. A regression tree was constructed to predict the length of ICU stay and explore the important indicators.

RESULTS

Multivariate Cox analysis found that shock and nutrition support need were statistically significant risk factors for prolonged length of ICU stay. Altogether, seven variables entered the regression model, including age, APACHE II score, SOFA score, shock, respiratory system dysfunction, circulation system dysfunction, diabetes and nutrition support need. The regression tree indicated comorbidity of two or more kinds of shock as the most important factor for prolonged length of ICU stay in the studied sample.

CONCLUSIONS

Comorbidity of two or more kinds of shock is the most important factor of length of ICU stay in the studied sample. Since there are differences of ICU patient characteristics between wards and hospitals, consideration of the data-mining technique should be given by the intensivists as a length of ICU stay prediction tool.

Putting Research Findings into Clinical Practice: Feasibility of integrated evidence-based care pathways in otorhinolaryngology head and neck surgery at Sultan Qaboos University Hospital, Oman

OBJECTIVES

A perception exists that clinicians in Oman are reluctant to adopt evidence-based practice (EBP). This pilot study was undertaken to study the feasibility of using EBP pathways at the point of care in otorhinolaryngology head and neck surgery. The ultimate aim was to facilitate EBP with the probability of developing a new system for implementing research findings/translational research at the clinical point of care.

METHODS

A cross-sectional prospective questionnaire pilot survey of clinicians at Sultan Qaboos University Hospital (SQUH), Oman, a tertiary care medical centre, was undertaken. Respondents included 135 physicians and surgeons with between 3 months and 25 years of clinical experience and included personnel ranging from interns to senior consultants, in areas ranging from primary care to specialist care.

RESULTS

Of those polled, 90% (95% confidence interval (CI) 85-95%) either strongly agreed or agreed that evidence-based practice protocols (EBPP) could help in decision making. A total of 87.4% of participants (95% CI 81.8-93%) either strongly agreed or agreed that EBPPs can improve clinical outcomes; 91.8% of participants (95% CI 87.2-96.4%) would use and apply EBPP in day-to-day care if they were available at the point of care and embedded in the hospital information system.

CONCLUSIONS

The perception that clinicians at SQUH are reluctant to adopt EBP is incorrect. The introduction of EBP pathways is very feasible at the primary care level. Institutional support for embedding EBP in hospital information systems is needed as well as further outcome research to assess the improvement in quality of care.

How can we improve cancer care? A review of interprofessional collaboration models and their use in clinical management

BACKGROUND

Multimodal cancer care requires collaboration among different professionals in various settings. Practice guidelines provide little direction on how this can best be achieved. Research shows that collaborative cancer management is limited, and challenged by numerous issues. The purpose of this research was to describe conceptual models of collaboration, and analyze how they have been applied in the clinical management of cancer patients.

METHODS

A review of the literature was performed using a two-phase meta-narrative approach. The first phase involved searching for conceptual models of collaboration. Their components and limitations were summarized. The second phase involved targeted searching for empirical research on evaluation of these concepts in the clinical management of cancer patients. Data on study objective, design, and findings were tabulated, and then summarized according to collaborative model and phase of clinical care to identify topics warranting further research.

RESULTS

Conceptual models for teamwork, interprofessional collaboration, integrated care delivery, interorganizational collaboration, continuity of care, and case management were described. All concepts involve two or more health care professionals that share patient care goals and interact on a continuum from consultative to integrative, varying according to extent and nature of interaction, degree to which decision making is shared, and the scope of patient management (medical versus holistic). Determinants of positive objective and subjective patient, team and organizational outcomes common across models included system or organizational support, team structure and traits, and team processes. Twenty-two studies conducted in ten countries examining these concepts for cancer care were identified. Two were based on an explicit model of collaboration. Many health professionals function through parallel or consultative models of care and are not well integrated. Few interventions or strategies have been applied to promote models that support collaboration.

CONCLUSIONS

Ongoing development, implementation and evaluation of collaborative cancer management, in the context of both practice and research, would benefit from systematic planning and operationalization. Such an approach is likely to improve patient, professional and organizational outcomes, and contribute to a collective understanding of collaborative cancer care.

Introducing HCM v3.0: a standard model for hospital case management practice

PURPOSE/OBJECTIVES

Like the professional definitions of case management, the practice of hospital management is a dynamic process. However, because hospital case management programs come in so many shapes and sizes, there is a widespread tendency to forego the process and instead focus on the static tasks associated with utilization review and discharge plan arrangements. As a result, the research identifying best practices is inhibited and hospital case management practice is constrained. This article speaks to the need for a standard approach to hospital case management and offers a model that positions the hospital case manager as the primary patient advocate and physician partner that are among the essential ingredients for successful participation in accountable care organizations, progression-of-care management, and transitions of care support.

PRIMARY PRACTICE SETTING

Acute care hospitals, integrated delivery systems.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

1. Hospital case managers must practice in accordance with the professional process of case management. 2. Hospital case management programs must be structured in such a way as to support the professional process of case management. 3. The roles and responsibilities of hospital case managers must be unmistakably defined to make certain that proactive advocacy is visible as the essential ethical obligation.

Building collaborative partnerships in critical care: the RN case manager/social work dyad in critical care

PURPOSE/OBJECTIVES

More than 5 million patients are admitted annually to intensive care units (ICUs) in the United States. As the life expectancy of the population continues to lengthen, we should expect to see a proportionate increase in the burden of acute and chronic illness as well as a rise in the demand for critical care services. The case management dyad team of nurse case manager and social worker enhances and supports the critical care team through the implementation of collaborative interventions that focus upon the (1) minimization of inpatient transitions, (2) reduction of cost by decreasing the length of stay, (3) promotion of patient and family satisfaction through efforts of advocacy, and (4) enhanced discharge planning.

PRIMARY PRACTICE SETTING(S)

Hospital ICUs.

FINDINGS/CONCLUSIONS

In the critical care setting the professional partnership of the RN case manager/masters in social worker (RN/MSW) dyad is a core component in the linkage of the ICU support system and it enhances the functioning of the ICU multidisciplinary team. The efforts of the dyad team are congruent with the goals of patient care, with the desires of the family, and with the mission of the organization. Shared goals and a shared commitment to professional practice provide the essential building blocks of the dyad relationship. The dyad structure presents an opportunity for RN case managers and social workers to integrate their strengths and skills in a collaborative patient-centered effort.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The RN/MSW dyad structure as a model for case management practice promotes continuity of care and strengthens professional relationships. The case manager and the social worker have many shared responsibilities; therefore, a partnership that promotes continuous collaboration and communication is essential to the achievement of successful patient care outcomes. The professional partnership that evolves, as depicted by the RN/MSW dyad structure, enhances the organizations' mission to deliver quality patient-centered care.