Jonathan P. Weisul, MD, FACEP, has direct responsibility over both case management and contracted hospitalist services at CHRISTUS St. Frances Cabrini Hospital in Alexandria, La., where he is regional chief medical officer and vice president of medical affairs. To him, the two most important aspects of the relationship between hospitalists and case managers involve communication and respect.
“In our system it’s a very collaborative approach where the case manager presents options to the physician as discharge planning progresses and the physician explains the progression of the patient’s treatment to the case manager,” he says.
In the early days of managed care, Dr. Weisul says, case management received some bad press in that “it was perceived that their interest was [just] getting patients out of the hospital. And I would say that one area where the communication fails is the oftentimes misheld belief on the physician’s part that case managers are trying to practice medicine,” he explains. “Communication usually involves the case manager presenting options to a physician in a way that would be in the best interest of the patient—not trying to usurp any authority from the physician-patient relationship.”
The greatest partnership between hospitalists and case managers occurs when they both share options and needs, and perhaps the best venue for sharing occurs at interdisciplinary meetings. All case managers interviewed for this article stress the importance of daily meetings as a clear advantage for an effective discharge plan.
L. Greg Cunningham, MHA, CEO of the American Case Management Association (ACMA), headquartered in Little Rock, Ark., says the best thing hospitalists and case managers can do to improve their working relationship is “communicate about their patient caseload first thing in the morning.” Both are sharing information. “One is sharing more expectations of what needs to be done for the patient,” he says. “The other is sharing more expectations about what the physician needs to do in terms of decision-making such as getting signatures on forms and communicating with the patient and family.”
Theresa Brocato, RN, BSN, CPUR, manager of case management and social work at CHRISTUS St. Frances Cabrini Hospital, has been in that position for almost four years. For seven years before that she worked in managed care for Ochsner Health Plan of Louisiana. In her opinion hospitalists can be most helpful to case managers by thinking proactively.
“We have a very proactive discharge planning department,” she says of her department of nine case managers (all nurses) and five social workers who work directly with patients and families, “because as soon as the patient gets to the hospital we start the discharge planning.”
The case managers interview patients and their family and let them know what their estimated time to wellness will be. “We base the estimate on a working DRG [drug-related group],” she says. “We talk to the hospitalist up front, and [we] say, for instance, ‘For this patient, the average time to wellness is about six days, and we need to start preparing for that ultimate discharge. Is there anything you foresee that you might need on discharge, such as equipment or home health?’ And then we start coordinating with the physicians to get the orders in place and get everything set up so that they have a smooth transition at the time of discharge.”
But Dr. Weisul says this kind of communication can be misinterpreted. “Communication seems to fail in the most difficult cases where the physician seems to perceive that the progress of the medical care might not be going on [in] as timely [a manner] as he or she might expect and feels that the case manager, in … looking at when the appropriate discharge time might be, is pressuring the physician,” he says. “But the reverse is true: What they’re doing is just asking for input from the hospitalist [or other] physician as to progress on the path of returning the patient to health and just looking to the future.”