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Case Managers

Oct. 16, 2019 – The dynamic case managers I met with today wear many hats and take on a variety of responsibilities. Working closely with patient families to address their child’s health needs, this team of nurses provides assessment, planning, care coordination and advocacy for options and services.

My visit had perfect timing since it fell during Case Management Week! We began by discussing the longevity of this team, and it is impressive. Of the 21 team members, four have worked at Rady Children’s for more than 30 years and three for more than 20, with a combined longevity of 389 years! Most are assigned to specific units, such as the Peckham Center, 4 East, the NICU and 3 East Surgical.

Next, we touched on some of the skills and tasks required of case managers. While it’s difficult to list every duty that case managers have, they focus most heavily on these roles:

  • Provide discharge planning
  • Perform care coordination through family need assessment
  • Conduct utilization reviews for all patients admitted
  • Assess the level of care patients receive on a daily basis
  • Work proactively to prevent any insurance denials or delays at discharge
  • Facilitate communication between care providers
  • Perform initial and follow-up consultations
  • Link patient to additional services lines and resources
  • Eliminate task and intervention duplication to facilitate effective care plan implantation and follow-up
  • Ensure continuity of care by avoiding fragmentation or duplication of services

As with many roles at Rady Children’s, it takes a special type of person to do this job. When asked what types of qualities are important, I heard responses including “patience,” “flexibility,” “persistence” and “out-of-the-box thinking.” It also takes sound clinical training and background, the ability to educate patients and care providers, and the strength of character to give patients a voice and advocate for patient and family needs. And did I mention communication skills? These case managers have the unique ability to connect with a wide range of people, including clinical care providers, families, patients, vendors and insurance companies. It’s almost like learning a special language for each one!

We then dove into some of this team’s most-used tools and processes. For example, requests for some case management services, such as discharge readiness assessments, are now built into Epic. This service begins with a nursing assessment, which triggers a case manager assessment that is documented in Epic. Last year, case managers at Rady Children’s made between 156 and 333 consults every month.

A visual example of how case managers work with many entities to coordinate care

Another platform this team works with is called InterQual, which helps to quantify why a patient is in the Hospital. InterQual assesses the most clinically appropriate care level for more than 95 percent of reasons for admission.

Case managers also play a big role in care coordination for complex patients when they are discharged. For example, for a ventilator-dependent patient, case managers work with teams from across the organization, including nursing, nutrition, social work, HomeCare and pulmonology. Case managers are responsible for getting a home health referral, making sure respiratory equipment and other devices are delivered, verifying medications with the pharmacy, verifying transportation, and confirming a shift nurse and respiratory therapist are available during discharge.

During my visit, we also looked at a scenario similar to what case managers see daily, in which they must evaluate whether a patient meets the criteria to be admitted to the Hospital. In most cases, insurance will not provide coverage unless there is a medical diagnosis. As I learned, there can be a lot of hoops to jump through to make sure patients get the insurance coverage they need!

Adding a new stamp to my growing collection

For all of the varied tasks they take on, case managers have measurable, positive effects on our organization. Their work reduces readmissions and length of stay and prevents avoidable delays. They cover multiple responsibilities within one complex role and bring their problem-solving and detective skills with them every day. Thank you for your diligence and for being such tireless advocates for our patients and families.