Effective methods for communication between Case Managers and Physicians A CM Leaders Perspective

Hospital Case Management has been in existence for over 30 years. In that time many changes have occurred that have influenced the case manager-physician relationship. Changes to reimbursement, focus on length of stay, the development of evidenced based medical necessity criteria and pay for performance measures are some of the changes that have greatly impacted the decision-making process in admitting and discharging patients. Case managers have had to revise their methodologies to meet current demands and to prove their financial impact and importance to hospital organizations. One key element in the process of evolution of case management has been the ability to understand how to effectively communicate a discharge plan to a physician. Timing, the ability to discuss clinical milestones and how and when to approach the physician is crucial to the collaborative process. Many facilities are structured in such a manner that an interdisciplinary team is used to reach a consensus on the ability to discharge a patient.

The common misconception of the interdisciplinary approach is that consensus is reached on a discharge date, when in reality there is no meeting of the minds and the physician dictates the outcome of when the patient is discharged based on the information provided by the team in each member’s sub-specialty. The physician generally will have a plan to treat his or her patients with expectations based on outcomes rooted in science and the art of medicine, better understood as clinical milestones. To assist the physician in the final decision the case manager needs to bridge the gap of communication. He or she needs to be prepared in more ways than in previous years and has to evolve into a care coordinator with roots in discharge planning, utilization management, facilitation and mediation, financial management and advocacy. It takes time, experience and education to achieve success, but most importantly it takes an individual willing to accept a dynamic environment in which communication and collaboration are at the forefront of success.

The role of the care coordinator in determining when a patient is ready for the next level of care must be systematic, based on elements of medicine and in conjunction with best practice acts and incorporates clinical milestones. The essentials of a case management plan of care are needed to achieve outcomes that are beneficial to not just the patient but to the organization as well.

“The case management plan of care differs from the nursing care plan frequently used in the acute setting in that it is not diagnosis-driven but encompasses all aspects (medical, financial, psychosocial, functional, etc) that affect the client’s ability to achieve their defined outcomes” (Kelly, 2003)

Many current practicing case managers rely on the physician to dictate the discharge date; others use evidenced based criteria to determine eligibility from an insurance perspective while the most successful meld different information into determining when the patient is ready for the next level of care. Evidenced based guidelines (EVB) or criteria as commonly referred to such as MCG, InterQual and others have set parameters for deciding the next level of care but lack the ability to bend to the individual patient from the perspective of the physician. Additionally new tools have been created to allow artificial intelligence software to interact with the EMR to better predict an estimated discharge date based on many clinical factors and produce a DRG based length of stay.

Physicians are not keen on being told that “their patient is not meeting criteria”; that statement is an instant door closer for many. The case manager needs to approach the case from a clinical milestone pathway by understanding the care plan the physician has initiated. Being able to use EVB in a non-threatening, non-insurance laden form is the key to achieving success.

Care Coordination is a specialization of a role that is complex and includes multiple communication lines. In many hospitals the case manager must juggle the information that needs to be delivered on the plan of care to many physicians that may be on a case. Consultants play a key role in the care of the patient and may not always be available to directly communicate with other physicians let alone the case manager, thus creating a gap in the continuity of care that needs to be put in place like a jig-saw puzzle to attain the desired outcome. Being able to understand the clinical goals of each specialty and tie it to the overall plan of care is essential when formalizing a communication method with the attending that is in ultimate control of the patient.

“This complexity is further confounded in community hospitals where, in addition to the various medical specialties represented in the daily communication patterns, the number of different physicians practicing the same specialty adds multiple additional communication channels” (Arford, 2005)

Effective communication can be achieved when the care coordinator has a plan that will be accepted by the physician in their own terms but not in a conciliatory fashion. Negotiating and advocacy goes hand in hand with collaboration. As case managers move forward in time it well serve them well to accept that they need to develop negotiation skills that will make them an inseparable partner to the physician.

Being able to continuously evolve and use tools to communicate is essential. Today there are many electronic forms of communication that assist to reach those on the treatment team to gather necessary information but a good old face to face to conversation with the treating physician about what the patient needs will always be in the best interest of the patient and assist with the plan for discharge.

Reference:

Aford, PH, Nurse-Physician Communication: An Organizational Accountability, Nursing Economics. 2005; 23(2):72-77

Kelly, T, Development and Use of a Case Management Plan of Care, Inside Case Management, 2003, Volume, 10 (3), p 1-5