We have put nurses on the front line of care management (CM) without the information and skills they need to succeed. This gives them grief from both sides as providers feel harassed by their questions, and administrators gripe about L3nt5h of Stay (LOS).
CM nurses also seem to struggle with the fast-paced, information-dense requests for determining medical necessity for tests, procedures, and extended lengths of stay (ELOS). As I medical director, I found that I usually had to wade through tons of chaff to find the kernel of information I needed to make the decision. I think provider documentation is a problem (see last week’s post about documentation to establish medical necessity), but I also believe that nurses don’t always know how to ask the right questions.
For example, a skilled nursing facility(SNF) care team requested ELOS for a member. For each request, I had to re-read several paragraphs that outlined the past history before I could glean that she could walk 300 feet, needed maximum assistance to stand and minimal assistance to perform activities of daily living. I didn’t see any description of a clinical condition that clarified WHY she had these deficits and why someone who can walk 300 feet and needs minimal assistance can’t be in the community. I asked for more documentation, but kept getting the same long summary with no additional information.
I arranged a conference call with the SNF primary care team (nurse, PT/OT, SW). Within ten minutes, I knew that the member was not able to bend her knees at all. She could not sit in or transfer from a standard chair, nor bend to dress below the waist. She was in an active program of progressive bracing with specific objectives for the degree of joint flexion she would need to be independent. These resources were not available in the community. BINGO! I was able to approve that ELOS with objective measure to determine necessity of future requests. The only reason it took as long as it did was that the primary care team wasn’t used to getting these kinds of questions. They wanted to keep giving me diagnoses. They finally got it when I used one of my favorite Woodsonisms: It’s not the WHAT; it’s the SO WHAT!
When ELOS requests come before me, I can usually scroll back through past notes in the data base to review the history up to that point. I just need to know what is going to be different going forward. I need to know specific barriers to discharge and since we are managing care, I also need the psychosocial assessment, outlining whether the member’s personal, environmental, and financial resources would support care in a less intensive site. This means having a partnership with community services, or at least a resource list.
Despite Affordable Care Act goals, most healthcare professionals have no idea how to decrease institutional care because most of the training is still in the hospital. A hospital director of nursing once asked me what a psychosocial assessment was , and I said to myself, “Toto, I don’t think we’re in Kansas anymore.”
We healthcare professionals learn to do things TO people to determine whether they are going to get better or die. Today, patients do neither. We are called to contend with chronic conditions, and we find ourselves having to switch gears to do things FOR people. This requires a broader, multi-disciplinary approach that most doctors, nurses, health care administrators, and even social workers don’t learn. Evaluating and trying to remove barriers to providing care in the community requires skill in functional and cognitive assessment. It requires active partnership with social, behavioral health, legal, adult protective services, law enforcement professionals, and clergy. With the reality of an increasingly complex medico-legal environment, a working knowledge of clinical medical ethics (which is more than just HIPAA) is essential. Most important is the ability for active clinical decision-making innovative care planning. I hate the term “think outside the box” because there is no box. Also, patients don’t read the book, and they don’t follow algorithms.
I am developing a curriculum and certification for managed care nurses, which I plan to extend to other multidisciplinary team members in the future. I’m planning spring focus groups of veteran managed care nurses and I’d appreciate some more feedback from other folks in the trenches. These are the focus group questions:
What did you NOT learn in nursing school that you wish you had?
What would you say to new grads who want to choose careers in managed care?
Which topics are essential to developing superlative skills in CM/UM.
Are these the right questions?
I look forward to hearing from you.
Dr. Woodson is a geriatrician, eldercare consultant, and author. The second edition of her popular family caregiving resource, TO SURVIVE CAREGIVING: A Daughter’s Experience, A Doctor’s Advice, and a new book, The Doctor is IN: Answering Your Questions About How to Survive Caregiving are due out in 2016. Visit www.drcherylwoodson.com for information about upcoming events and to schedule presentations and consultations.
The photographer is Dr. Woodson’s sister-in-law, Dr. Brackette F. Williams. The two are collaborating on a picture book of inspirational affirmations that will also come out this year.