collaborative case management - winter 2010

8/14/2019 Collaborative Case Management - Winter 2010

1/15T h e O f f i c i a l P u b l i c a t i o n o f t h e A m e r i c a n C a s e M a n a g e m e n t A s s o c i a t i o n

A P u b l i c a t i o n f o r H o s p i t a l a n d H e a l t h S y s t e m P r o f e s s i o n a l s

W i n t e r 2 0 1 0 V O L U M e 7 , i S S U e 4

4Impacting Legislation at the Local Level: Key Considerations for the

Case Manager

4Case Management in a Pandemic: Has the Profession Codified its

Obligations?

4Care for the Psychiatric Patient: Historical Basis for the Treatment of the

Mentally Ill

4Increased Communication, Decreased Length of Stay: The Anatomy of

an Effective Intervention


2/15

C A S E M A N A G E M E N T

Case Management in Hospital and Health Care Systems is a

collaborative practice model including patients, nurses, social workers, physicians

other practitioners, caregivers and the community. The Case Management process

encompasses communication and facilitates care along a continuum through

effective resource coordination. The goals of Case Management include the

achievement of optimal health, access to care and appropriate utilization of

resources, balanced with the patients right to self-determination.

A p p r o v e d b y A C M A M e M b e r s h i p , N o v e M b e r 2 0 0 2

3Impacting Legislation at the Local Level:

Key Considerations for the Case ManagerBy Christy Whetsell, RN, BSN, MBA, ACM

7 Case Management in a Pandemic: Has theProfession Codified its Obligations?By Mark Repenshek, PhD and Jane Hounsell, MSW, LCSW

10 Care for the Psychiatric Patient: Historical Bfor the Treatment of the Mentally IllBy Karen Askew, RN, BSN, ACM

12 Increased Communication, Decreased LengStay: The Anatomy of an Effective InterventioBy David Reyes, MD

I n T h I s I s s u

2

W i n t e r 2 0 1 0 V O L U M e 7 , i S S U e 4

Publisher

L. Greg Cunningham, MHA

CEOACMA / Little Rock, AR

[email protected]

editorial staff

Randall ArcherEditor

ACMA/Little Rock, AR

[email protected]

Tyler Neese

Editorial StaffACMA/Little Rock, [email protected]

editorial board

Jane Hounsell, MSW, LCSW

Lead Medical Social WorkerCase ManagementColumbia-St Marys Hospitals/Milwaukee, WI

Val Kraus, MBA

Director

Admissions / Case Management / ChaplainBoulder Community Hospital/Boulder, CO

Sandra Mullings, MSW, LCSW, C-ASWCM

Director

Care CoordinationEmory Crawford Long Hospital/Atlanta, GA

Charlotte Spacek, RN, MSN, MBA-HCM, CPUM

DirectorCase ManagementMartin Memorial Health System/Stuart, FL

Tricia Thomas, PhD, RN, MSN

Assistant Professor and CoordinatorClinical Nurse Leader ProgramUniversity of Detroit Mercy/Detroit, MI

Collaborative Case Managementis publishedquarterly by the American Case Management

Association (ACMA), 11701 West 36th Street,Little Rock, AR 72211.

Telephone: 501-907-ACMA (2262).

Subscription is a benefit of membership in ACMA.

Full and Associate memberships are available at$135.00 per year. Student membership is open toindividuals enrolled in a full time academic programat $60.00 per year. More detail about membershipcategories is available at the ACMA web site,

www.acmaweb.org or by calling 501-907-2262.An annual subscription is available for non-

members at $100 per year. Single issues can bepurchased by non-members for $25.00 per issuesubject to availability.

Photocopying: No part of this publication may bereproduced in any form or incorporated into anyinformation retrieval system without the writtenpermission of the copyright owner. For reprintpermission, please contact ACMA,

11701 West 36th Street, Little Rock, AR 72211.

The statements and opinions contained in the

articles ofCollaborative Case Managementaresolely those of the individual authors andcontributors and not of the American CaseManagement Association. The Publisher and Editordisclaim responsibility for any injury to personsor property resulting from any ideas or productsreferred to in the articles or advertisements.

Copyright 2010

American Case Management AssociationAll rights reserved
http://www.acmaweb.org/http://www.acmaweb.org/


3/153

C O L L A B O R A T I V C A s M A n A G M n T

continued on page 4

Historically, case management has had little representation at

the legislative level. Many are currently working to remedy this lack

of representation through concentrated advocacy efforts; however,

there is still much work to be done. Case managers serve as the

front line between patients and the care and services they require,

and thus it is imperative that case managers work to share their

expertise with policymakers in order to influence health care

legislation and policy.

Effectively advocating on behalf of case management doesnot require one to travel to the nations capitol a number of

opportunities exist for case managers to influence legislation and

impact policy within their regions. This article will examine case

managements influence and provide practical advice on how to

actively engage local legislation at both the state and regional

levels in order to build effective partnerships, and ultimately

impact national policy and provide a voice for case management

in legislation.

What CaSe ManageMent haS tO Offer

Case managers are uniquely positioned to provide legislators

with multiple perspectives from within health care. Case managers

serve as advocate and liaison for both the patient and hospital

administration, which allows them to accurately reflect the actual

impact of a particular initiative and the outcomes for both the

patient and the organization.1 Case managements collective finger

is continually on the pulse of health care, and thus case managers

recognize issues throughout the continuum, as it is the nature of

case management practice to coordinate resources and identify

solutions to these issues.

DeVeLO a Lan

To take action in the legislative arena, one must first identify a

cause. This cause might stem from a need or an issue related to

current practices or processes within case management, or it couldbe an issue which carries the potential to create future

complications or impair case management practice. Journals and

online directories are excellent resources to use when searching for

information on various issues (see Figure A).

Effective advocacy requires forethought and thorough

preparation. It is not enough to simply walk into a legislators office

and request change. Rather, one should approach key decision

makers with a well-constructed set of goals and potential solutions

to the issue. When developing a plan, it is helpful to consider the

following strategic questions:

1. What do I want? (Goals)

2. Who can give it to me? (Audience, key players or power holders)

3. What do they need to hear? (Messages)

4. From whom do they need to hear it? (Messengers)

5. How can I get them to hear it? (Delivery)

6. What do I have? (Resources)

7. What do I need to develop? (Gaps)

8. How do I begin? (First Steps)

9. How do I tell if it is working? (Evaluation)2

iDentify the Key DeCiSiOn MaKerS

The first step in any advocacy initiative is identifying figures that

are influential within legislation. Local senators, representatives, and

legislative committees are excellent resources and points of contact

in an advocacy effort. Some case managers might find their state

secretary of health is also a valuable ally in influencing change and

impacting legislation. Agencies or groups whose goals, priorities,and needs are similar to those of case management are also

excellent advocacy resources, and represent partnership

opportunities. Such agencies or organizations can include:

Nursing Associations

Social Work Associations

Insurance Commissioners

Community Living Associations

Senior Centers

impc Lslo h Locl Lvl: Ky Cosdos o h Cs MBy Christy Whetsell, RN, BSN, MBA, ACM

touou ps dcd, l c lslo s scl mpcd ospl cs mm pcc o v o lvls.

Lslo cul b cosdd s p o Ud Ss movm owds om cos umb o vs v

pol o u mpc cs mm d w wc p c s dlvd.

The Centers for Medicare and Medicaid Serviceswww.cms.gov

The Federal Registerwww.gpoaccess.gov/fr

U.S. Department of Health and Human Serviceswww.hhs.gov

figUre a

RSURCSINITIATIVS IMPACTING HALTH CAR
http://www.cms.gov/http://www.gpoaccess.gov/frhttp://www.hhs.gov/http://www.hhs.gov/http://www.gpoaccess.gov/frhttp://www.cms.gov/


4/154

There are a number of resources and guides available that can

provide advocates with information on local legislators and keydecision makers (see Figure B). Building relationships with local

representatives helps establish inroads at the national level in the

event the issue or initiative being pursued requires further action.

KeyS tO SUCCeSSfUL aDVOCaCy

The Proper Approach

When working to leverage case managements influence within

legislation, approach is of the utmost importance. It is vital to

structure conversations so that the issue becomes personal to the

representative. It is important to consider the following factors

when crafting ones approach to a legislative meeting:

Assessment - Careful examination of a legislators stance and

active initiatives is central to forming the proper approach.

Such examination might reveal that another representative is

more qualified to address the issue in question or that the

legislator already is working to achieve the desired outcome,

providing common ground.

Go through the proper channels - To reach key decision

makers, one must respect the systems in place and follow

proper protocols. Legislators are much more likely to agree to

meet with those who have requested a meeting in advance and

have been added to the schedule, rather than those who arrive

at their offices and demand a meeting.

Accurate, timely facts - Facts and data only strengthen a

discussion, but it is essential that such figures are current and

accurate. Out-dated facts and metrics can hurt ones credibility,

and they do little to strengthen a presentation. Facts and data

also should be presented on the basis of cause and effect.

Information that showcases the financial ramifications also can

be beneficial. Case scenarios that demonstrate cost savings that

could have been achieved had the proposed solution been

implemented are powerful tools in influencing legislators.

Respect for time - It is important to remember that legislators

time is precious. Not unlike case management professionals,

legislators schedules are very hectic and demanding, which in

some cases might only allow them 15 or 20 minutes for a

meeting. The fact that a meeting is brief does not mean it will

not have an impact or achieve the desired outcome. Time is a

key consideration, so concisely presenting ones case and

possible solutions is often much more effective than a

drawn-out interaction. The less information to sort through,

the better.

Listen - Though it is important to present ones case and

purpose for the meeting, it is equally important to listen. An

active dialogue and mutual respect between both parties will

help establish a lasting relationship, which can greatly benefitfuture endeavors.

Willingness to compromise - It is important to enter a meeting

with the realization that the desired outcomes or

improvements might not be feasible exactly as they are

presented, however, this does not spell defeat. The willingness

to work together to reach a compromise is key to effective

advocacy, and is often necessary in order for both parties to

come to an agreement.

Leverage Case Managements Influence

Few lawmakers have a clinical background, nor do they always

fully comprehend the effects of a particular issue or initiative on the

patient, or the impact it might have on how patient care is provided.

In this regard, it is generally wise to ask legislators whether they are

familiar with hospital case management. If he or she responds that

they are not, take the opportunity to educate them, and clearly

define case managements role in the care process. If the lawmaker

is familiar with case management, provide further insight and help

expand their understanding of the role.

Case examples and real-life scenarios are also effective in

bringing the issue to a more personal level. For example,

addressing Medicare part D and its negative implications for the

patient might not clearly translate for a Senator or Representative.

Rather, explaining how provisions in Medicare part D have forced

many patients who require IV antibiotics to be placed in skillednursing facilities (SNF), preventing them from returning home and

creating a shortage of beds for the SNF, may be far more powerful.

Such case examples and scenarios help provide context for the

issue or initiative in question and add a great deal of validity to

ones argument.

Keep Constituents in Mind

Constituents are another key factor in effectively advocating on

behalf of case management. Legislators work to serve their

constituents, and it is essential when discussing an issue or

impc Lslo Locl Lvl: K Cosdos o Cs M (continued from page 3)

w w w . a c m a w e b . o r g

Legislation currently beingconsidered as part of the United

States movement towards reformcontains a number of initiatives thathave the potential to further impact

case management and the way inwhich patient care is delivered.

continued on page 5


5/155

initiative to make a clear correlation between the representatives

constituents and the issue in question. For example, when pointingout errors in a specific initiative, the ideal approach would be to

explain the way this initiative has a negative impact on those in the

legislators specific region or district. This can be an opportune time

in a meeting to introduce potential solutions to the issue. As

previously mentioned, requesting change does little to sway those

in influential positions, but approaching the issue with a clear

solution or set of alternatives will help establish one as a key

resource and possible contributor.

Strength in Numbers

Ones effectiveness as an advocate also multiplies when part of

a larger concentrated effort. Coordinating an advocacy effort in

ones area, which involves a number of case managementprofessionals from various backgrounds and concentrations,

increases the impact of each advocates efforts. This by no means

suggests the efforts of one individual advocate will not be fruitful,

but there is strength in numbers. If a representative meets with

several case managers from within his or her state or district who

are all focused on the same set of issues and priorities the need for

action and resolution is strongly magnified and reinforced.

OStaCLeS tO effeCtiVe aDVOCaCy

The fact that hospital case management is a relatively new

practice is perhaps the greatest challenge to successfully advocating

on its behalf. Though case management practice is constantly

evolving and growing, the number of case management

professionals in the United States is still relatively small, compared

with other health care professions. As previously mentioned,

education is a key element of legislative influence. If it becomes

clear that a representative is not informed, it is imperative to

provide education on the role of case management and its impact

on patient care.

Another challenge many encounter in advocacy and policy

efforts is a lack of focus on a specific issue. If advocating as part of a

larger effort and collective voice speaking on behalf of case

management, it is imperative that each case manager remains

focused on the priorities and goals established as part of theinitiative. Multiple positions, or diversions to separate and

unrelated issues, only serve to dilute the message and minimize

case managements effectiveness to impact policy and legislation.

COnCLUSiOn

With the changes taking place in the current structure of the

U.S. health care system, it is critical that case managers speak out

and work to influence and help redefine initiatives that threaten to

negatively impact patient care, as well as case management

practice. Being an effective advocate does not require action at the

steps of the U.S. Capitol. Participating in comment periods and

petitioning representatives within ones district are practical and

effective vehicles for advocacy that will help shape initiatives and

issues, and provide a voice for case management in legislation.

Christy Whetsell, BSN, RN, MBA, ACM, has been the Director of Care

Management at West Virginia University Hospitals since 2006. She

earned her BS in Nursing from West Virginia University in Morgantown,

WV, and her MBA from the University of Phoenix. She has sixteen years

of experience in healthcare, including experience in critical care nursing,

emergency nursing, and multiple areas of case management.

referenCeS

1 DeRoche, J. Affecting Change from Daily Practice to Congress: Legislative

Advocacy and Case Management. Collaborative Case Management; 2009;6(4): 7-9.

2 Advocacy Institute, Washington DC, 2002

impc Lslo Locl Lvl: K Cosdos o Cs M (continued from page 4)


Case managers serve as the front linebetween patients and the care andservices they require, and thus it is

imperative that case managers workto share their expertise with

policymakers in order to influencehealth care legislation and policy.

U.S. Senatewww.senate.gov

U.S. House of Representativeswww.house.gov

USA.govwww.usa.gov

National Conference of State Legislatorswww.ncsl.org

figUre b

RSURCSLCAL, STAT, & NATINAL LGISLATRS
http://www.senate.gov/general/contact_information/senators_cfm.cfmhttp://www.house.gov/house/MemberWWW_by_State.shtmlhttp://www.usa.gov/http://www.ncsl.org/?tabid=17173http://www.ncsl.org/?tabid=17173http://www.usa.gov/http://www.house.gov/house/MemberWWW_by_State.shtmlhttp://www.senate.gov/general/contact_information/senators_cfm.cfm


6/156


This article will examine the social work and nursing codes of

ethics to provide an analysis of their respective adequacy of

response to the call specifically, the National Association of Social

Workers (NASW) Code of Ethicsand the American Nurses

Association (ANA) Code of Ethics. Most importantly, this article will

examine whether this turn to professional codes of ethics is

sufficient to address this special concern of the case manager in

pandemic preparedness planning.

the rOfeSSiOnaL rOLe Of the CaSe Manager

The American Case Management Association (ACMA) Standards

of Practice and Scope of Services states the case manager adheres to

professional standards of practice and his or her professional code of

ethics.3 The standard of practice includes facilitating care along a

continuum through effective resource coordination.4

The critical question for this article is whether or not, or to what

extent, the standard of practice shifts in a pandemic. For example,

will the criteria for what constitutes a safe and appropriate discharge

be redefined? Will minimum standards of care for the professionalcase manager be redefined? How will patient choice be constrained

when beds are needed (i.e. must the patient/family accept the first

available bed in a skilled nursing facility without the opportunity to

tour?) In considering staffing plans in a pandemic, how far outside of

their scope of practice would registered nurse (RN) case managers

and social work case managers be expected to work? To what extent

might RN case managers be diverted to more clinical nursing roles

and away from their case management responsibilities? Many of

these questions require an understanding of the professional

commitments made by case managers. Because of the ethical nature

of these questions, it seems relevant to begin by turning to the Code

of Ethics as a basis for understanding the duties and claims society

may make upon case managers when facing a pandemic.

OLigatiOn tO rOViDe MeDiCaL Care in a anDeMiC

In 2006, G. Caleb Alexander, published results from a national,

cross-sectional, random-sample survey conducted in 2003

concerning physicians preparedness for bioterrorism and other

public health priorities. In order to gain a sense of physicians

self-reported willingness to treat in the midst of public health

emergencies, Alexander asked three questions, two of which are

relevant here:

(a) Would [you] volunteer in medical reserve corps to serve in

the event of a public health emergency

(b) Would [you] be willing to put [your] self at risk of

contracting a deadly illness if it was the only way to save

others lives

Emergency physicians responded in the affirmative 54% and48%, respectively, to these two survey questions, relatively mirroring

their primary care colleagues 51% and 50%, respectively.5

Yet these data do not offer any insight as to the motivation for

such willingness to treat, that is as a duty or otherwise. In fact, the

University of Toronto Joint Centre for Bioethics (JCB) Pandemic

Influenza Working Group found that while some health care

professionals did meet the needs of the public during the infectious

disease threat of severe acute respiratory syndrome (SARS) in 2003 in

Toronto, approximately 30% of the reported cases were among

healthcare workers.6This fact lead to serious concerns among some

health care professionals as to whether or not they were obligated to

care for those infected with SARS, and for others a direct failure to

report to work.7

This reality was highlighted in a study which examined public

health agencies in Maryland. The study found that nearly half of the

workers for public health were not compelled by a sense of duty to

report for work in the face of a pandemic.8 Given the surge required

for a pandemic, the issue of whether a duty exists for health care

workers to meet public need has become a matter of paramount

concern for health care system planning.9

One group that has made an explicit claim with regard to a

professionals obligation to provide medical care is the American

Medical Association in the document Physician Obligation in

Disaster Preparedness and Response adopted in 2004. The

document states:

National, regional, and local responses to epidemics,

terrorist attacks, and other disasters require extensive

involvement of physicians. Because of their commitment to

care for the sick and injured, individual physicianshave an

obligation to provide urgent medical care during disasters.

This ethical obligation holds even in the face of greater than

usual risks to their own safety, health or life. The physician

workforce, however, is not an unlimited resource; therefore,

when participating in disaster responses, physicians should

balance immediate benefits to individual patients with the

Cs Mm dmc: hs osso Codd s Oblos?By Mark Repenshek, PhD and Jane Hounsell, MSW, LCSW

t pol o pdmc luz s s (modld o 1918-lk luz pdmc): 1.9 mllo ds, 90 mllo popl

ll, l 10 mllo popl osplzd, w lmos 1.5 mllo qu sv-c us Ud Ss.

1

a ccl quso s sucd cs lu cocs w xss du o povd mdcl c o ps mds o suc pol

o l d l o l c possol.2 alou s sc mou o lu wc ddsss

x o pscs possol oblos o p, ll xss d x o wc l c m ms

sm lvl o oblo. W suc dscussos v ocusd o du o oblo, m ssocos cll o u o

possol cods o cs o sbls bss o s dus d oblos.

continued on page 7


7/157


ability to care for patients in the future [emphasis added].10

Whether this position can be extrapolated to include healthcare professionals in general is still unresolved. In fact, it is unclear

whether an organization in which only about 25% of U.S.

physicians are members creates enough of a force to ground the

obligation for all U.S. physicians.11However, the expectation is

clear: physicians have an obligation to provide urgent medical care

during disasters.

The JCB working group has gone further, but with the same

tenor of obligation, extending the obligation or duty to provide

medical care in a pandemic or similar disaster to all health care

workers. The JCB working group, under C1 Health Care Workers Duty

to Provide Care During a Communicable Disease Outbreak, notes:

The duty to care for the sick is a primary ethical obligation for

health care workers for a number of reasons, including:

1. The ability of physician and health care workers to provide

care is greater than that of the public, thus increasing their

obligation to provide care

2. By freely choosing a profession devoted to care for the ill,

they assume risks

3. The profession has a social contract that calls on members

to be available in times of emergency. (In addition, they

largely work in publicly supported systems in many

countries)12

Despite expanding this duty to provide medical care to health

care workers in general, the document does go on to note that,

health care workers ethical codes should provide important

guidance on such issues as professional rights and responsibilities.

It is important for health care professionals, from doctors to nurses

to hospital and ambulance staff, to articulate codes or statements of

ethical conduct in high-risk situations, so that everyone knows

what to expect during time of communicable disease crises.13

It isunclear if these codes should merely provide guidance on the

implications of a presumption of a duty to provide medical care

among varying healthcare professionals in light of competing

duties such as families, friends and co-workers, or whether that

very presumption is one to be addressed by each disciplines code.

Whatever the case, it is clear that the expectation of a code of ethics

for health care professionals should speak to

1. The matter of a duty to provide medical care

2. Any limits to that duty (i.e., level of risk to self and others)

the CaSe ManagerS DUty tO rOViDe MeDiCaL Care

in a anDeMiC

Given the multidisciplinary nature of case managers

professional background, this article will explore both The NASW

Code of Ethics, as well as the ANA Code of Ethics.

The NASW Code of Ethics Section One: Social Workers Ethical

Responsibilities to Clients states,

Social Workers primary responsibility is to promote the

well-being of clients. In general, clients interests are primary.

However, social workers responsibility to the larger society

or specific legal obligations may on limited occasions

supersede the loyalty owed clients, and clients should be so

advised [emphasis added].14

Section 6.01 follows titled: Social Workers Ethical

Responsibilities to the Broader Society; Public Emergencies,

Social workers should provide appropriate professional

service in public emergencies to the greatest extent possible

[emphasis added].15

At first glance it appears that the NASW has addressed both of

the JCB working groups goals for a code of ethics related to the duty

to provide medical care and appropriate limits to that duty. However,

this code of ethics for the NASW falls short on both accounts. First,

note that although the code suggests clients interests are primary,

the subordinate clause that precedes this statement qualifies that

obligation as in general. One may infer from this context thatoutside the context of pandemics or other public health

emergencies the primacy of the clients interests may not necessarily

be primary as it relates to the case managers obligations.

In fact, the code goes on to make this inference more explicit by

noting responsibility to the larger society or specific legal

obligations may on limited occasions supersede the loyalty owed

clients. Without stating explicitly the type of responsibility that

might be owed the larger society at the sacrifice of the individual

client, one could envision any number of social goods that could

potentially be constructed (i.e., the good of family, the good of

Cs Mm dmc: hs osso Codd s Oblos? (continued from page 6)

Professional codesof ethics form the

benchmark againstwhich professionals

judge their competenciesand behavior, and createnormative standards towhich the professional

ought to strive.

continued on page 8


8/158


collegiality, the good of client placement to increase system

efficiencies, the good of the health systems sustainableinfrastructure for public health delivery). Depending on the good

owed to the larger society, the primacy of the patient may be

absent any corresponding duty or obligation on the part of the

case manager. One could easily envision that a professionals

obligations to deliver certain services likely would be constrained

by the circumstances of a pandemic or other public health disaster.

To suggest that the obligation to the patient herself can be

diminished or trumped by competing goods is a complete

shift in the endpoint or recipient of that obligation.

Section six of the NASW Code of Ethics attempts to address the

issue of a duty or obligation to provide medical care in public

emergencies by directly

addressing the issue of a public

emergency. Again, however, use of

a qualifying phrase, in this case

to the greatest extent possible,

makes the obligation less clear.

Where possibility creates the

contingency upon which

obligation hinges and the very

nature of a public health

emergency, or more specifically a

pandemic, presents the de facto

reality of limits, section 6.01 of the

NASW Code of Ethics does not

provide clear guidance.16

Unfortunately, ANAs code of

ethics for nurse case managers

suffers from some of the same

inadequacies as NASWs.

Provision 2 of the ANA Code of

Ethics reads,

The nurses primary

commitment is to the patient, whether an individual,

family, group, or community. 2.1 where conflict persists

[related to this primary commitment], the nurses

commitment remains to the identified patient.17

In contrast to the NASW Code of Ethics, the ANA Code of Ethics

does not qualify this obligation. Additionally, the ANA Code of

ethics does note that were there competing claims against this

primary commitment, the patients interests supersede. Overall, the

ANA Code of Ethics seems to meet both of the expectations of the

JCBs appeal to associations codes of ethics.

Still lacking from this code of ethics, however, is explicit

advisement in the context of public health emergencies, or for

pandemics specifically. In a review of ANAs position statements

since 1991, no statement addresses nursings responsibility in

public health emergencies, natural disasters, pandemics or

otherwise.18

The ANAs Disaster Preparedness & Response websiteoffers a link to the Institute of Medicine (IOM) report on

Establishing Altered Standards of Care in Disasters.19 Although

this IOM report does address the duty to provide medical care in

disasters, it is unclear whether this is intended to be simply a

preparedness planning document, a position consistent with the

ANAs position, or merely an available resource.

COnCLUSiOn: CODeS Of ethiCS anD ULiC heaLth

DiSaSterS - an aeaL

Carly Ruderman and colleagues argue the continuing silence

of codes of ethics [on the matter of pandemics and the duty to care]

is greatly problematic, both

clinically and normatively.

Professional codes of ethics form

the benchmark against which

professionals judge their

competencies and behavior, and

create normative standards to

which the professional ought to

strive. The challenging context

of a pandemic, which differs so

greatly from the day-to-day reality

of case management practice,

demands a code have been worked

out well in advance so as to

increase awareness and comfort

levels, perhaps resulting in

increased willingness to provide

care in uncertain and risky

conditions.20 Such a defined code

that responds explicitly to the

matter of a case managers duty to

the patient in the context of a

public health disaster or pandemic

also reinforces public trust.

Therefore, case management leaders should revisit

established codes of ethics specific to the matter of a duty to

provide medical care in a pandemic. While such codes can, andhopefully will, be established on a national level in the future, in

the interim period case management leaders can establish

standards at their own facilities. In doing so, case management

leaders proactively define the expectations of their staff during a

pandemic or disaster scenario.

When establishing codes, case managers should consider the

JCBs recommendations outlined above as a starting point in order

to assist in clarifying their role and multiple competing obligations

during a pandemic. An effective code should address the following

factors and key considerations:


The challenging context ofa pandemic, which differs sogreatly from the day-to-dayreality of case management

practice, demands a codehave been worked out well

in advance so as to increase

awareness and comfortlevels, perhaps resultingin increased willingness to

provide care in uncertain andrisky conditions.

continued on page 9


9/159


Case managements obligation to provide care

The risks case managers assume by choosing their

profession, and the implications of such risks upon the case

managers duty to provide care

Possible limits to case managements duty to provide

medical care, such as level of risk to self and others

Case managements professional rights and responsibilities,

so that expectations of case management in the event of a

pandemic or disaster scenario are clear

Staff input is critical, as each member of the case

management department may provide unique perspective

from their personal experience

Case managers serve as advocates for both the patient and the

organization they serve. By proactively defining case managements

responsibilities and duties in the event of a pandemic or disaster

scenario, case management leaders enable their staff to fulfill their

obligations to both parties, even when the correct course of action

may be unclear.

Mark Repenshek, PhD, is currently the Health Care Ethicist at

Columbia St. Marys in Milwaukee, WI, where he serves on an

Institutional Review Board, multiple Ethics Committees and offers

numerous educational opportunities for medical faculty and staff. He

earned his PhD in Health Care Ethics at Saint Louis University at the

Center for Health Care Ethics. In addition to his role at Columbia St.

Marys, Mark teaches at the Medical College of Wisconsin, University

of Wisconsin-Milwaukee, and at the Columbia College of Nursing. He

has authored numerous articles and a book in healthcare ethics.

Jane Hounsell, MSW, LCSW, is currently the Lead Medical Social

Worker in the Case Management Department at Columbia St. Marys,

where she also serves on the organizations Ethics Committee. She has

worked in hospital case management for 22 years. She earned her

MSW from the University of Wisconsin-Milwaukee.

enDnOteS

1 U.S. Department of Health and Human Services. HHS pandemic inuenzaplan part 1: strategic plan. The pandemic inuenza threat. U.S. Department

of Health and Human Services. 2005.

2 Heidi Malm, Thomas May, Leslie P. Francis, et al., Ethics, Pandemics, andthe Duty to Treat. AJOB 8 (2008): 4-19; Carly Ruderman, C Shan Tracy,Cecile M. Bensimon, et al., On pandemics and the duty to care: whoseduty? Who cares? BMC Medical Ethics (2006): 1-6 accessed at http://www.biomedicentral.com/1472-6939/7/5; Karine Morin, Daniel Higginson,and Michael Goldrich for the Council on Ethical and Judicial Affairs ofthe American Medical Association, Physician Obligation in DisasterPreparedness and Response. Cambridge Quarterly of Healthcare Ethics 15(2006): 417-431.

3 American Case Management Association, Standards of Practice & Scopeof Services for Hospital/Health System Case Management, (Little Rock, AR:ACMA, 2007) 12.

4 ACMA, Standards of Practice & Scope of Services for Hospital/Health

System Case Management, 2.

5 G. Caleb Alexander, G. Luke Larkin and Mathew Wynia. PhysiciansPreparedness of Bioterrorism and Other Public Health Priorities. AcademicEmergency Medicine 13 (2006): 1238-1241.

6 L.M. Fleck, Are there moral obligations to treat SARS patients? MedicalHumanities Report 25, no. 1 (2003): 3-4; Malm, et al., Ethics, Pandemics,and the Duty to Treat, 5; World Health Organization, Consensusdocument on the epidemiology of severe acute respiratory syndrome(SARS). Available at http://www.who.int/csr/sars/en/WHOconsensus.pdf(accessed on November 2, 2009).

7 Ruderman, On pandemics and the duty to care: whose duty? who cares? 2.

8 R.D. Balicer, S. Omer, D. Barnett, and G. Everly Jr., Local public healthworkers perceptions toward responding to an inuenza pandemic. BMC

Public Health 18 (2006): 99.

9 GC Alexander and M.K. Wynia. Ready and Willing? Physicians sense ofpreparedness for bioeterrorism. Health Affairs 22 (2003): 189-197; CCClark. In Harms Way: AMA physicians and the duty to treat. J Med Philos30 (2005): 65-87; L. Reid. Diminishing returns? Risk and the duty to care inthe SARS epidemic. Bioethics 19 (2005): 348-361.

10 American Medical Association: physician obligation in disasterpreparedness and response. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9067.shtml (accessed November 2, 2009).

11 CC Clark. In Harms Way: AMA physicians and the duty to treat. J MedPhilos 30 (2005): 65-87.

12 University of Toronto Joint Centre for Bioethics (JCB). Stand on Guardfor Thee: Ethical considerations in preparedness planning for pandemicinuenza. JCB Bioethics Pandemic Inuenza Working Group (November2005): 9; http://www.jointcentreforbioethics.ca/publications/documents/stand_on_guard.pdf (accessed November 2, 2009).

13 University of Toronto JCB, Stand on Guard for Thee, 10. http://www.jointcentreforbioethics.ca/publications/documents/stand_on_guard.pdf(accessed November 2, 2009).

14 National Association of Social Workers. Code of Ethics http://www.socialworkers.org/pubs/code/code.asp (accessed on 11-04-09).

15 http://www.socialworkers.org/pubs/code/code.asp (accessed on 11-04-09).

16 Ruderman, On pandemics and the duty to care: whose duty? who cares?, 3.

17 http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/DPR.aspx (accessed on 11-04-09).

18 http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/ANAPositionStatements/EthicsandHumanRights.aspx (accessed on 11-04-09).

19 http://www.nursingworld.org/MainMenuCategories/HealthcareandPolicyIssues/DPR/IOM-Report-on-Standards-of-Care.aspx(accessed on 11-04-09).

20 Ruderman, On pandemics and the duty to care, 3; see also, J Gommans.Coping with severe acute respiratory syndrome: a personal view of thegood, the bad and the ugly. NZ Med J 116 (2003): U456; A Campbell and KGlass, The legal status of clinical and ethics policies, codes ,and guidelinesin medical practice and research. McGill L J 46 (2000): 473.



10/1510

In practice, these factors present a myriad of challenges to the

case manager responsible for the patient, as the case manager

must develop an efficient plan of care which takes into account

the unique considerations and challenges associated with

psychiatric care. To effectively manage this patient population, a

case manager must be familiar with the regulations governing the

treatment guidelines for psychiatric patients in medical hospitals.Understanding the origin of these regulations can help unveil the

intent of the regulation, and render them more understandable

and applicable to daily practice. This article will provide a

historical context for the current standards and regulations

governing the care of psychiatric

patients, and the patterns

established as a result.

a LanDMarK CaSe

The current structure of

commitment law and the ensuing

effect on the psychiatric patient

population can be largely

attributed to the Supreme Court

case ofOConnor v. Donaldson, a landmark decision in mental

health law. OConnor v. Donaldson pitted the plaintiff, Kenneth

Donaldson, against the Florida State Hospital at Chattahoochee.

Donaldson, who was civilly committed to the state mental hospital

for 15 years, argued that he was not mentally ill and was a danger to

no one. Furthermore, Donaldson argued that if he was in fact

mentally ill, he received no treatment for his alleged illness.

The central issue the court identified in the case was a patients

fundamental right to liberty. The court held that a diagnosis of

mental illness does not, in and of itself, empower the state to

confine a person if they are not a danger to them self or others. Thecase also affirmed the right to treatment, meaning that a patient is

entitled to be given treatment that would provide him or her the

opportunity to be cured or to improve their mental condition.1

far-reaChing effeCtS

Although the courts decision was widely praised for the

plaintiff involved, it has had far reaching consequences for the

treatment of the mentally ill, and has resulted in drastic changes in

commitment law.

Following the Supreme Courts ruling, mental health codes

were revised and re-written and asylums across the U.S. closed their

doors. The Texas Mental Health Code, for example, now states that

mental health treatment must be provided in the least restrictive

setting (Chapter 571, Sec 004). This code also states that the least

restrictive appropriate treatment setting for a mentally ill patient is

the setting that:

1. Is available

2. Provides the patient with the greatest probability of

improvement or cure

3. Is no more restrictive of the patient s physical or social

liberties than is necessary to

provide the patient with the most

effective treatment and to protect

adequately against any danger the

patient poses to himself/herself or

others2

Under such revised legislation,

strict criteria and procedure must

be followed by healthcare providers

in order to require an individual to

submit to confinement.

iMaCt On the atient

Restrictions on confinement and treatment of mentally ill

patients enacted as a result ofOConnor v. Donaldson have, in many

cases, resulted in the postponement of treatment for the patient.

The longer the patients treatment is delayed, the more severe their

situation can become, and too often these patients are stabilized

and released only to be readmitted to the ED numerous times; this

is a situation with which case managers and social workers are

often familiar. Too often this cycle of stabilization, discharge, andreadmission has grave consequences for the patient.

One unfortunate reality of the courts decision is that it has

allowed many who are mentally ill to transition into the community

with little to no structure, support, or system for follow-up. For

those that are ill-equipped to function in society, this lack of a

support structure combined with inadequate preparation has

allowed them to become more vulnerable to exploitation and

abuse. These factors also contribute to a high rate of homelessness

among the mentally ill. In 2007, the U.S. Conference of Mayors

conducted a survey of 23 metropolitan areas. According to the


C o scc : hsocl ss o tm o Mll illBy Karen Askew, RN, BSN, ACM

W U.S. ospl mc dpms (eD), m pscc ps cosdd qu ls, s ull-dmd o sm cl. Suc ps c b souc sv, d o ld eD o xdd pods o m ul

bl o b plcd. Som o s clls c b bud o ps ml llss. howv, sc bod o

bo s d dl ulos ov m o pscc ps c lso c clls d bs o povd

c c.

Under the current need for treatment

statute, health care providers are often

restricted from holding mentally ill

patients to ensure they receive the

treatment they require...

continued on page 11


11/1511

report, 30% of the homeless populations surveyed had documentedmental illness.3, 4

Though the legislation enacted as a result ofOConnor v.

Donaldson has had a number of negative implications for patients,

the benefits of this landmark decision must not be overlooked. As a

result of the case, and its ensuing legislation, the mandate for states

to provide treatment for those confined due to a psychiatric

diagnosis was created. This mandate prevents mentally ill patients

from being warehoused in poor conditions with no treatment or

hope of release.

Furthermore, the Supreme Courts decision validated that each

person deemed not dangerous has an absolute right to live how

they choose, allowing many who may previously have been

confined to institutional life the chance to experience their

fundamental right to freedom.

COnCLUSiOn

Under the current need for treatment statute, health care

providers are often restricted from holding mentally ill patients to

ensure they receive the treatment they require, even with the

knowledge that the patients decision to not receive treatment is

being made with diminished decision making capacity. With these

factors in mind, it is imperative that case managers understand the

restrictions imposed on providers as a result of the revised

legislation, and proactively prepare for the barriers these

restrictions often cause as they manage patients with mental illness.It is also imperative that healthcare practitioners, who have

witnessed firsthand the restrictions placed upon the treatment of

mentally ill patients, are alert and remain constantly aware of

opportunities to act as an advocate in support of revising the

current statutes.

Karen Askew, RN, BSN, ACM, has been the Director of Quality Care

Management at San Jacinto Methodist Hospital in Baytown, TX since

2005. She earned her BSN from the University of Alabama at

Birmingham, and is currently pursuing her MSN in Nursing

Leadership at the University of Texas Medical Branch in Galveston,

TX. Her nursing career spans more than 33 years in acute care

services, and she has worked in hospital case management for thepast 14 years.

referenCeS

1 U.S. Supreme Court, OConner v. Donaldson, 422 U.S. 563 (1975). http://supreme.justia.com/us/422/563/case.html (accessed on 8-14-09).

2 Texas Mental Health Lawhttp://www.megalaw.com/tx/top/txmentalhealth.php (accessed on 7-6-09).

3 Audi, C., (2009, April) Helping the Homeless http://helpinghomeless. wordpress.com/2009/04/09/mental-illness-and-homelessness/ (accessedon 7-6-09).

4 OSullivan, A., Caughlan, J., Roberts, L., Dela Torres, L., Dixon, J., Holoman,K., et al. (2000, Oct) Mental Illness, Chronic Homelessness: An AmericanDisgrace, Healing Hands 4(5), 1-5.


C o scc : hsocl ss o tm o Mll ill (continued from page 10)

All Previous WebinarsAvailable in Recorded Format

J 20, 2010 Leadership and Change Future Changes

in Healthcare and the Role of Case Management

F 3, 2010 Optimizing Benchmarking in Case Management

How to Develop and Use Benchmarks

F 17, 2010 Case Review: Teaching Assessment to Resolution

1 Webinar$199

2 Webinars$299

3 Webinars$399

4 Webinars$499

5 Webinars

$599All Webinars

$799(Savings of $594!)

r i C i n g a C K a g e S

Register Online with Promo Code: collabcm and Save $100

www.acmaweb.org/Leadership

3 WeinarS reMaining in 2010

The Futureof Healthcare

Hospital Case ManageMent

Leadership Webinar series


12/1512


A Medical Directors Perspective

iDentifying SySteM iSSUeS

The need for improvement s in both LOS and communication was

identified by several members of the care team, including the

organizations case managers, chief of medicine and director of the

hospitalists, the hospitalists, and hospital administration, including the

organizations CFO. A meeting was held between these individuals to

determine what factors were causing the decline in performance.

This collective effort proved beneficial, as it allowed for multiple

perspectives on the issue to be shared, and revealed three key issues

as determined by the group which were contributing to the increase

in LOS: physician education, timing of meetings between hospitalists

and case management, and communication between hospitalists and

case management.

the interVentiOn

As is the case with most targeted initiatives, it is often beneficial to

research similar models, in order to build upon practices or systems

that have proven effective for other organizations. However, upon

researching interventions in place at other facilities, Southern Hills

staff was unable to identify a model which they felt could adequately

address the specific issues and concerns identified within the

organization. At this point, the decision was made to create and

implement a specific intervention to address those key issues

contributing to the consistent increase in LOS.

Physician Education

Based on the meetings discussion, it became clear that the

organizations physicians lacked a general understanding of case

management, and its role in the care process. Physicians were also

unfamiliar with the terminology commonly used by case managers, as

well as the types of reviews case managers perform on a daily basis.

To address the issue of education, a specific initiative was

employed, which was designed to raise awareness and provide

practical training in case management for the organizations

hospitalists. The education initiative was a joint effort, led by the

organizations case managers, as well as the chief of medicine and

director of the hospitalists.

The main focus of the initiative was on admission and discharge

criteria used by the organizations case managers. A general overview of

these criteria was provided, as well as a briefing on the terms involved

and the types of reviews case managers perform. This curriculum was

beneficial to the hospitalists to a certain degree; however, the

hospitalists gained a much clearer understanding of the case

management role when asked to personally perform sample reviews.

Each hospitalist involved in the intervention was assigned several

sample cases, and asked to score each case according to the criteria set.

Once each case was scored, the physicians were asked to justify their

evaluation as if presenting their case to a payor. The discharge criteria

manual followed by the organizations case management was a critical

element of the hospitalists hands-on education, as it provided guidance

for each of the cases they were asked to review, and also provided

context as to the guidelines case managers are required to follow.

Providing the hospitalists with not only an overview of the key

terms and issues faced by case management, but also with an

opportunity to experience the discharge process from the case

managers point of view, allowed them to gain a new perspective and a

greater understanding of the case management function and the

expectations placed upon case managers.

Timing of Meetings

The next focus of the intervention was the timing of the discharge

meetings. Prior to the intervention, Southern Hills hospitalists and

case managers held discharge meetings every morning. Morning

meetings had proven to be counterproductive, as they occurred at a

time that was far less than opportune for both parties. Mornings are

perhaps the busiest part of a hospitalists day. Hospitalists work to

address all their admissions in the morning, and concurrently work to

complete all of their discharges before 11:00 a.m. Additionally, the

hospitalist is trying to see all of their established patients who will be

staying an additional day before 2:00 p.m., which is typically when the

Emergency Department (ED) admissions pick up. Considering all of

these responsibilities, holding a discharge meeting in the morning

proved challenging to the organizations hospitalists.

Borrowing a concept from a hospitalist management group, an

icsd Commuco, Dcsd L o S: t aom o ecv ivoBy David Reyes, MD

i Dcmb 2008, Sou hlls Mdcl Cs (Sou hlls) ldsp cozd uvobl d ozos l o

s (LOS) mcs. t d sowd o coscuv qus, LOS d dull csd. a umb o ssus w dd s k

cobu cos o csd LOS, clud commuco bw ozos osplss d cs mm m. t

dcso ws md o mplm sc vo dsd o mpov commuco, povd pscs w duco o cs

mms ol c pocss, d mos mpol, dcs LOS.



13/1513


afternoon meeting time was determined to be ideal for both

parties. Based on this structure, the daily discharge meetings

were moved to 2:30 p.m.

During the meetings, case managers and hospitalists

discuss each patients diagnoses, discharge needs, level of

service, and barriers to discharge the following day. This focus

has allowed both case managers and hospitalists to proactively

plan for each patients discharge the day prior to discharge.

Communication

Communication is a key component to any successful

working relationship, and thus it is imperative to address any

communication issues as part of the intervention.

Many of the communication issues that were occurring could

largely be attributed to both parties misinterpreting what the

other was saying, and as a result, assumptions were being made

that were not healthy for the case manager-hospitalist

relationship as a whole. For example, prior to the intervention,

situations had occurred in which a hospitalist had determined

that a patient should be admitted to the hospital. Upon review,

one of the organizations case managers argued the contrary,

stating that the patient did not meet inpatient criteria. To the

physician who is not aware that the case manager is referencing a

score card that is based upon a set of established criteria, this

objection is interpreted as the case manager challenging the

physicians judgment as to whether or not the patient should be

in the hospital. Such instances proved to be detrimental to case

managements credibility with the organizations hospitalists, and

in some cases even fostered hostility between the two parties.

Such miscommunication is counter-productive to the

overall care process, and in many cases relates back to the

physicians unfamiliarity with case management terms and

processes. For this reason, the interventions communication

focus was a component of the education initiative, through

which case management terms and procedures were clearly

defined. The implications of misinterpreting such terms andprocedures were also addressed in order to convey the

importance of effective communication.

Another key factor in improving the communication

between case management and the hospitalist team was case

managements willingness to recognize that terms and concepts

that they routinely employ are foreign to most hospitalists.

Terms such as severity of illnessand intensity of serviceare

typically not defined or discussed in medical school, residency,

or fellowship, and thus physicians often make assumptions as to

what terms such as these mean when case managers discuss

them in practice. In this regard, case managers were encouraged

to carefully frame their interactions with hospitalists to avoid

giving the physician the impression that they are challenging the

physicians judgment, or undermining their authority.

For instance, a case manager might relate to a hospitalist

that a particular patient does not have the intensity of service to

justify their stay in the hospital. To the physician who is

unfamiliar with this term, and is interpreting this statement

literally, the implication is that he or she, as a provider, is not

doing enough for the patient, or that the treatment plans should

be modified to play the game. A physician would generally

resent such a statement. An alternative approach that is more

effective is for a case manager to explain to the hospitalist that

the payors, who only have access to the chart, do not possess the

same understanding as the physician who sees the patient, and

thus it is imperative that the chart clearly state certain

information in order for the payors to understand how ill the

patient is, and why they need to stay in the hospital.

eVaLUating SUCCeSS

To evaluate the progress of the intervention, the facilitys

providers were divided into two groups hospitalists who had

participated in the intervention, and the non-hospitalists whohad not participated in the intervention. This structure provided

an opportunity to evaluate the intervention by examining

hospitalist LOS compared to non-hospitalist LOS.

Non-hospitalists spend most of their time in the outpatient

setting and only a small part of their time in the hospital setting.

Non-hospitalists system interests are primarily related to the

outpatient setting.

Hospitalists generally register a shorter LOS than non-

hospitalists. Therefore examining the difference in LOS at one

point in time would not be the most accurate measure of the

icsd Commuco, Dcsd Lh o Sy: th aomy o ecv ivo (continued from page 12)

Another key factor in improving

the communication between case

management and the hospitalist team

was case managements willingness to

recognize that terms and concepts

that they routinely employ are foreign

to most hospitalists.



14/1514


interventions effect on LOS. For this reason, the decision was

made to examine the change in LOS for each provider group pre

and post-intervention.

From the hospitalist perspective the general assumption

was that their participation in the intervention would result in a

decreased LOS, while those who did not participate in the

intervention would experience no change in LOS.

Case managers predicted that a decrease in LOS would be

universal between both hospitalist and non-hospitalists, as case

management was participating in the intervention, and also

participating in the care of the patients being seen by the

hospitalists and non-hospitalists alike.

Evaluating the progress and success of the intervention also

presented a unique opportunity to examine whose participation

in the project was more important the physicians

participation, or case managements participation.

OUtCOMeS

Outcomes of the intervention were analyzed nine months

into the initiative. Average length of stay (ALOS) for both

hospitalists and non-hospitalists was examined by quarter for

the three quarters leading up to the intervention and the three

quarters following the intervention.

The trend in the hospitalists ALOS showed a progressive

increase prior to the intervention, and a gradual decrease

following the intervention; the overall decrease in ALOS being

approximately 0.5 days (see Figure A).

Although the non-hospitalists data showed more variability

than that of their hospitalist counterparts (consistent with this

group having more physicians, and a broader spectrum of

practice patterns), the analysis revealed the same trend of an

increase in ALOS leading up to the intervention, and a decrease

following the intervention (see Figure B).

The fact that both groups experienced a decrease in ALOS

following the interventions implementation can largely be

attributed to the common denominator between the two parties case management.

The findings supported the case managers hypothesis. This

finding was a powerful measure, as it further validated case

managements importance in the care process, and clearly

illustrated their ability to influence change.

Further analyses were performed by the organizations

decision support team to determine MSDRG-specific LOS. The

decision support team prepared data by provider group and

time period of interest and divided the physicians into four

groups to evaluate the metrics:

Hospitalists pre-intervention

Hospitalists post-intervention

Non-hospitalists pre-intervention

Non-hospitalists post-intervention

The MSDRG-specific data also revealed a significant

decrease in LOS in both groups following the intervention.

Heart failure/shock with major co-morbidities proved to be

the MSDRG with the most significant decrease in LOS. For

hospitalists specifically, the difference in LOS in the category of

heart failure/shock with major co-morbidities between pre and

post-intervention was approximately 3.5 days reduction in LOS

(see Figure C).

Based on the results of the MSDRG analysis, there were also

some categories in which LOS increased. These categories were

in the minority, as most significantly decreased, and the increase

was minimal typically .5 to 1 day. However, one increase in

LOS following the intervention revealed a systems issue

unrelated to the initiative.

COnCLUSiOn

The intervention implemented at Southern Hills achievedits goals both in terms of reducing LOS and improving

communication and relationships between case management

and the hospitalists. Communication between case managers

and the physicians has greatly improved as a result of the

initiative, and physicians are now more familiar with case

management processes and terminology.

The outcomes achieved as a result of the intervention

provide solid, quantifiable proof of case managements

influence on the care process. These outcomes also clearly

demonstrate the power of collaboration in improving rapport

amongst health care professionals, all in an effort to create a

more efficient care process.

David Reyes, MD,has been the Medical Director of Hospitalists

at Southern Hills Medical Center since 2007. He earned his

MD from Vanderbilt University in Nashville, TN. He has ten

years of experience as a physician, with over five years of

experience as a hospitalist director. He also currently serves as

Chief of Medicine and Physician Advisor to Case Management

for Southern Hills Medical Center. He recently added the

medical directorship of hospitalist program at Centennial

Medical Center to his duties.

icsd Commuco, Dcsd Lh o Sy: th aomy o ecv ivo (continued from page 13)



15/15


-4 -3

3.5

4

4.5

5

5.5

-1 1-2 0 2 3 4

ALOS

-4 -3 -1 1-2 0 2 3 4

3.5

4

4.5

5

5.5

ALOS

Hospitalist ALOS by Quarter

Non-Hospitalist ALOS by Quarter

Quarter Relative to Intervention

Quarter Relative to Intervention

Point of Intervention

Point of Intervention

MS DRG

291

682

193

683

689

871

208

641

190

287

378

Absolute Change (days)

-2.2

-1.7

-1.6

-1.6

-1.6

-1.0

-0.8

-0.6

-0.6

-0.4

Percent ChangeMS DRG Description

Heart Fail/Shock W McC

Renal Failure W CC

Kidney/Uti W McC

Nutri Misc Meta Dis Wo Mc

Ch Obst Pulm Dis W McC

Gi Hem W CC

figUre a

figUre b

figUre C

-45%

-38%

-27%

-29%

-30%

-24%

-16%

-28%

-14%

-23%

-17%

-3.5

Renal Failure W McC

Simp Pneu/ Pleu W McC

Septi/Seps Wo Mv96+Hr Wmcc

Circ Dis No Mi Wcath Womcc

Resp Sys Dx W Vent

collaborative case management - winter 2010

Documents