Can HIM Professionals Cross the Line into Case Management?

Can HIM Professionals Cross the Line into Case Management?

Can HIM Professionals Cross the Line into Case Management?

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(Editor’s note: The following article is based on a seminar titled “Case Management: A New or Alternative Career Path for HIM Professionals,” presented by Maxine Uttenreither, ART, at the American Health Information Management Association’s 1996 Annual Convention).

ADVANCE Assistant Editor

Case management is a new area of specialty that is springing up in health care facilities, insurance companies and health maintenance organizations as a process to help meet the mandates of today’s cost-cutting, do-more-with- less environment. If you’re not sure what case management is, you might want to continue reading, for it’s a potential alternative career path for savvy health information management (HIM) professionals.

Case management (CM) is an offshoot of utilization management (UM). In UM, objective, measurable clinical indicators are used to determine the appropriateness of a patient’s admission and continued stay in an acute care facility.

As a process for managing patient care, CM goes one step beyond the boundaries of UM. A case manager reviews and coordinates patient care—working with doctors, nurses and staff from other departments in a health care institution—to ensure that each patient is receiving proper medical care, with appropriate cost containment. In tracking the patient’s care, the case manager also has frequent interaction with the patient and his family. Controlling costs, using resources efficiently and providing effective, quality care are considered to be the primary objectives of CM.

Historically, both UM and CM have been tied to the nursing profession because they require a knowledge of clinical information. And while people with HIM backgrounds have had much success breaking into UM positions, CM still remains unchartered territory for most HIM professionals. But it doesn’t have to stay that way.

“Registered record administrators (RRAs) and accredited record technicians (ARTs) already possess many of the skills needed to become case managers,” said Maxine Uttenreither, ART, founder and president of Healthcare Resource Management Group, a consulting firm that specializes in case management. “Any HIM professional who is willing to learn new things and become accountable for patient care and outcomes can break into this field.”

For Uttenreither, the path to case management wasn’t exactly a clear-cut, paved road. Instead, she had to blaze the trail that would lead her into this new career.

Uttenreither had been performing concurrent coding reviews for a hospital client as a consultant for another company. “Concurrent coding can be a back door for HIM professionals who want to get into a full-blown case management program,” she commented. “It is one of the more administrative duties of a case manager.” Uttenreither noted, however, that not all organizations choose to include concurrent coding in their case management programs.

While working for this client, Uttenreither noticed that staff members from many other departments, including nurses, physicians and utilization review (UR) personnel, were requesting and reviewing the same patients’ records.

“We were all looking at the same identical information, but for our own separate reasons,” she noted.

Never one to be shy, Uttenreither began to ask a lot of questions. “I basically pushed my way in,” she admitted. “I am by nature very curious and interested in learning new things. Also, I’m always looking for more efficient ways to work. So I asked the physicians and nurses, ‘What do you want to find in the record? How do you use this data? What criteria are you using?'”

In time, Uttenreither realized that one person could be reviewing the record and gathering all of the disparate data elements together, including coding, UR, discharge planning and quality indicator information. She believed that this person could be an HIM professional, despite the fact that the clinical background associated with this area of expertise is not typically as extensive as that of a nurse or a physician.

“Locating information in the record and using a hospital’s or an insurance company’s criteria to determine its implications is very formulaic,” Uttenreither commented. “The case manager doesn’t have to know how to treat the patients; they merely have to be good at communicating with physicians and nurses and following the clinical pathway that these practitioners have laid out for the patient.”

According to Uttenreither, a case manager’s key functions can include performing certain coding responsibilities, such as assigning and updating working diagnostic related group (DRG) codes and estimated lengths of stay (LOSs); handling certain UM duties, such as preadmission screenings, certifications, admission and continued stay reviews and quality assessment screenings; and assuming some of the responsibilities of a social worker, such as planning discharges.

“HIM professionals have a strong background in many of these areas, the most obvious being the coding elements,” Uttenreither asserted.

And, while the clinical background of HIM professionals is certainly not as comprehensive as that of nursing professionals, “RRAs and ARTs have taken courses in anatomy and physiology. We have knowledge relating to diagnoses and procedures; we can read and understand ancillary reports,” Uttenreither declared. “We may not be able to interpret these reports as nurses can, but this isn’t a necessary skill for case management anyway.” In addition, Uttenreither attested, most HIM professionals have extremely solid organizational capabilities, which is a tremendous asset when functioning as a case manager.

Uttenreither also noted that the key to CM, as an area of specialty, involves becoming less of a specialist and more of a generalist. “Case management is a cross-functional arena,” she stated.

In fact, when Uttenreither’s consulting firm has a client who would like to implement a CM program, she selects individuals from certain departments—usually, coders from the HIM arena, nurses working in a UR or quality assurance (QA) capacity and social workers/discharge planners—who will then cross-train each other so that everyone learns all of the job duties and skills relevant to the position of case manager. “Each type of professional brings their unique background and expertise to the program, ensuring well-rounded case managers,” Uttenreither said.

Should every HIM professional attempt to break into case management in their facility? “Well, while I do firmly believe every HIM professional could learn to be a case manager,” Uttenreither cautioned, “it is not necessarily a job for everyone.”

The challenges that must be faced when training for this position are daunting. “It can be very exacting because there are so many new processes to learn,” she stated.

In addition, once you have learned the basics of CM, it will still remain a very demanding job for a variety of reasons. “First of all, you need a very thick skin,” Uttenreither noted.

Because CM is an emerging arena, there are often many different groups within an organization trying to claim this specialty as their own. “There are ‘turf wars’ in some facilities over who is best suited to do the job,” Uttenreither said. “The nurses claim that they should be the only ones allowed to do CM; the social workers believe they are the only ones properly trained to for the job. It can be extremely stressful to be caught in the crossfire of a political skirmish within your workplace.”

These “turf wars” can result in hard feelings that do not disappear overnight. Many times, case managers have to interact with departments that may not be very receptive to them at first. “You need the forte to speak with nurses and physicians, and to continue asking questions, even when you are being treated very poorly, until you understand what you came to learn,” Uttenreither said.

Add to this the fact that a case manager’s job is always very demanding and often unpredictable. “Of course, there are some static duties and responsibilities with this position, but it is far from routine,” Uttenreither related. “You can barely plan your day because you’re dealing with a human element—patients—and new situations will pop up that will make your day extremely hectic. Every day is a new patient with new problems that will require unique and different solutions. Sometimes, these problems take three or four days to resolve.”

Work hours are not necessarily constant, either. “You have to be flexible,” Uttenreither commented. “You can’t always leave for the day just because it’s five o’clock. If a situation develops at 4:45 p.m., you are going to have to stick around.”

Uttenreither noted that those who want to pursue CM as a career must possess two essential characteristics: vision and commitment. “You have to have the vision to realize that eventually, you will be able to do this job,” she said, “And the commitment to overcome the many different obstacles and difficulties that will crop up as par for this course. You are not going to manage in this position if you have a tendency to think, ‘I can’t learn this; I’m no good at that,’ or if you are expecting ‘normal’ hours.”

After reading the cautionary words of warning above, one might wonder why anyone would want to pursue CM. But rest assured, there are rewards. “In my opinion, the two greatest benefits to becoming a case manager are the personal growth you will experience and a feeling of accomplishment from having mastered something really challenging,” Uttenreither asserted. “In addition, case managers are extremely marketable professionals. Once you’ve learned CM, you possess a broader skill set and range of experience. And it’s a ‘hot’ career right now, with many hospitals looking to implement CM programs. There are a lot of job opportunities for case managers.”

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