Case Management Departments

[Peg H.]

We are developing a Case Management Department. I am interested in the structure and function of Case Management/ Care Coordination Departments in Acute Care Hospitals. What areas report to this department? What function do they serve, etc???

[LasVegasRN]

Most case managment departments function in acute care hospitals by doing utilization review/discharge planning/care coordination.

Most insurance companies have their own case managers that come into the hospital for this purpose, but the hospital based case managers usually deal with the uninsured, Medicare, and Out-of-Area admissions.

Usually the case managers are assigned to areas under their expertise. For example, the nurses with Peds/OB experience have those areas. ICU nurses typically cover the units and ER.

The hospital evaluates the effectiveness of the case management department by BED DAYS. They want to see, by case management's intervention, how many acute days have been saved. If normally your customary ICU length of stay is 5 days, and after a period of time your department has been able to impact the average by decreasing it to 3 days, you've saved a ton of money. The same goes for all the units, ER, and med-surg floors.

Remember, the bottom line is SAVED DAYS. In it's advanced stage, the case management department helps with expediting patients through their stay. An example of this would be cutting down the LOS of your CABG's by getting them moved to a lower level of care as soon as possible and medically appropriate.

Another component to a successful hospital-based case management department is social workers. You are going to need assistance with community resourcing especially with indigent cases, John or Jane Doe cases, and issues dealing with Adult and Child protective services.

The areas that report to the case management department is usually your insurance verification department, admitting, and the ER.

Your big goal will be to work collaboratively with the Chief of Staff and the hospital Administrator. This is crucial when you need to deal with uncooperative physicians - especially the one's who delay discharging patients for flimsy reasons.

Hope that helps...