C O L L A B O R A T I V E C A S E M A N A G E M E N T
The Unique Function of Nurse Case Managers on Psychiatric Units
in Acute Care Hospitals
By Jan Limero, RN, ASN, BA, CCM
The inclusion of psychiatric units in the acute care hospital setting creates potential operational benefits. These include the ability to better
manage psychiatric patients in the hospital through increased availability of clinically trained staff, and transfers to the in-house psychiatric unit
alleviating, if temporarily, the pressure to find immediate placements for psychiatric patients. However, there are fundamental differences
between psychiatric units and other units in an acute care hospital. The unique diagnoses and treatments as well as the differences in staffing
models and expertise of the clinical staff create unique challenges.
Baystate Medical Center in Springfield, MA is a 632-bed hospital
with a 27-bed psychiatric unit. Payer interactions, as well as all
discharge arrangements, had traditionally been performed by the
clinical social workers assigned to the psychiatric unit. Utilization
review (UR) nurses, who were not specifically assigned to the unit,
performed other utilization tasks such as daily case review and criteria
evaluation for continued inpatient treatment. These staff members were
assigned to perform utilization functions for the psychiatric unit, with
assignments rotated periodically. Eventually, hospital administration
identified the emergence of problems related to utilization functions on
the psychiatric unit, namely: increasing scrutiny by payers, and a
corresponding increase in unnecessary denials.
To manage these challenges more effectively, Baystate Medical
Center aligned certain functions on the psychiatric unit with RN case
management staff, seeking to leverage their extensive utilization
management (UM) experience and medical background. This change
has demonstrated improved hospital reimbursement outcomes, denial
rates and payer interactions.
PSYCHIATRIC UNIT UTILIZATION MANAGEMENT
Prior to the addition of an RN case manager, the psychiatric unit’s
clinical social workers were responsible for insurance reviews and direct
interactions with payers – functions that fell outside of their training
and skill set. For example, information that may be, in the clinical
professional’s opinion, of key importance in a patient’s treatment and
progress may not equate to the information that is most desired by
psychiatric care managers of payer organizations. The result of this
mismatch was a high level of unnecessary denials, as well as a reduction
in clinical staff availability for patient care. The addition of a unit-
assigned RN case manager to perform all utilization functions brought
to the team needed experience in payer interactions, medical criteria,
and denial/appeals management, allowing the clinical social workers
more time for their core task of patient care. This dedicated case
management assignment replaced the former rotation of UR Nurses
through the unit, and with consistent attention, unique differences
between UM functions on a medical-surgical unit and on the
psychiatric unit quickly became apparent:
Payer Scrutiny
On medical-surgical units, cases are typically evaluated daily
against a criteria set for continued inpatient stay. The medical case
manager can generally fax documentation to the payer
demonstrating that the patient meets inpatient criteria for the day.
This is commonly accepted as sufficient, though a small number of
payers prefer telephonic review. For behavioral health cases,
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insurance companies commonly subcontract their psychiatric care
management to a company specializing in this field. These
specialized companies apply a more intense level of scrutiny to
each day of a patient’s stay. The payer’s psychiatric care manager
also commonly applies additional measures, beyond those that are
included in a criteria set. This more intense level of scrutiny can
often take on the character of the payer attempting to direct care to
varying degrees. In response to this increased payer scrutiny, case
review must also become more intensive and should proactively
focus justifications of services.
Justification Methodology
Although many criteria sets are available to evaluate psychiatric
inpatient necessity, the process for developing justification for an
inpatient psychiatric stay is not dependent only upon criteria. This
is a function not only of increased payer scrutiny, but also of the
nature of psychiatric diagnoses, whose symptoms can be more
difficult to capture and present than most medical diagnoses. For
example, disorganized thoughts of a schizophrenic patient are
more difficult to demonstrate through review than presenting a
case of pneumonia where an increased white cell count, respiratory
distress, and an impressive chest film are documented.
The case manager must learn what information is important to
each payer, and how to extract this from either review of the
medical record or discussion with the care team to compile a
thorough argument of medical necessity that will meet the payers’
expectations. Justification that will be meaningful to all payers starts
the major rationales for inpatient psychiatric admission:
4 the presence of suicidality;
4 the presence of homocidality; or
4 active psychosis.
However, the nuances of each case become increasingly
important as patient presentation becomes less clearly defined and
more complex, and to justify treatments for conditions outside of
these three diagnoses. Thorough knowledge of what each payer
wishes to see in order to justify continued inpatient care is essential.
Communication
The unique character of justification for a psychiatric stay and
the intense scrutiny applied by psychiatric care managers of payer
organizations necessitates modified communication methods. On
medical units, a significant amount of payer and case manager
reviews are conducted by fax. In contrast, on psychiatric units
such communications are conducted almost exclusively by
 w w w . a c m a w e b . o r g
telephone. Psychiatric care managers want to discuss the case
personally, and are typically not satisfied to review summarized
written information only.
Importance of Relationships
Frequent verbal case reviews and updates provide the case
manager an opportunity to develop collegial relationships with the
psychiatric care managers of payer organizations. It is important to
cultivate these relationships as they provide a foundation of
credibility for future interactions and case discussions.
EVOLVING MEDICAL NEEDS ON PSYCHIATRIC UNITS
Including a medically trained, unit-based RN case manager in the
psychiatric unit care team has proven even more effective than first
anticipated as the psychiatric patient population began to reflect an
increasing incidence of medical comorbidities that require post-discharge
support. An increased level of complex medical comorbidities is even
more common in the geriatric population, who comprise a growing
percentage within the psychiatric population. This trend is also more
prevalent in the psychiatric units of medical hospitals than at stand-alone
mental health facilities, which typically require a patient to be without
acute medical needs before receiving them in transfer. When a patient has
a psychiatric diagnosis among other medical diagnoses, it is common that
he or she is placed on the psychiatric unit with their medical treatments
still in progress rather than be managed on a medical unit.
The result is a change in the character of the care that must be
provided on psychiatric units – it is less purely psychiatric care than in
the past and requires more varied expertise than needed in prior models.
While the primary mission remains to provide psychiatric multidisciplinary
treatments, acute medical issues must frequently be addressed in the
patient’s overall plan of care, through the point of discharge.
This places additional demands and expectations on the traditional
multidisciplinary team members: psychiatrists, clinical social workers,
counselors, and psychiatric nurses. These additional expectations,
however, are not always realistic – although these professionals
continually gain expertise in managing the medical comorbid
conditions of their patients. To provide the necessary support for this
unit, Baystate Medical Center also added a full time physician’s assistant
to the unit’s interdisciplinary team. This individual performs physical
assessments, addresses all day-to-day medical concerns, and
coordinates any needed consultative services both during the
admission and in aftercare planning. The case manager and physician’s
assistant work in conjunction with the traditional multidisciplinary
team to ensure the complex medical needs of the patients are met at
both the acute level of care and post-discharge.
DISCHARGE ARRANGEMENTS
The increasing numbers of patients with medical comorbities on
psychiatric units began to necessitate the frequent inclusion of medical
components in discharge planning. This posed certain challenges,
however, for the clinical staff on the psychiatric unit at Baystate Medical
Center, whose previous area of expertise in discharge planning centered on
post-discharge psychiatric or substance abuse needs. The addition of the
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case manager’s expertise in medically based discharge planning proved
valuable to manage these challenges. The collaboration between the RN
case manager and the clinical social workers provides improved capability
to develop comprehensive and appropriate discharge plans. Clinical social
workers take the lead role in discharges to skilled nursing facilities, assisted
living facilities, or psychiatric stepdown levels of care such as partial
hospitalization, detoxification or day treatment. The RN case manager
takes primary responsibility for discharges to acute rehabilitation, long-
term acute care units (LTACs), and medical home care. The two roles
collaborate on all complex discharges, such as difficult placements.
Placements options for long-term psychiatric care and
governmental controls on psychiatric transfers vary significantly in
different areas of the country. However, common in almost all areas is a
scarcity of beds available to receive psychiatric patients who require
long-term placement. Compared to its medical units, Baystate Medical
Center’s psychiatric unit faces a more difficult placement procedure for
those patients needing long-term care. Most long-term psychiatric units
in Massachusetts are state managed, with admission applications made
through the Department of Mental Health. Patients must meet certain
eligibility criteria to apply for admission to these facilities. An extremely
limited number of skilled nursing facilities will consider patients with
psychiatric illness for admission. At the skilled nursing facilities that are
most able to provide this care, waits for placement are commonly
several months to a year.
IDENTIFYING PROCESS IMPROVEMENT OPPORTUNITIES
As a result of the unique characteristics that differentiate psychiatric
units from medical units, comparisons and metrics for psychiatric units
will vary. Without careful attention, challenges, issues and performance
improvement needs can be underserved. At Baystate Medical Center,
case management has a goal to increase identification of performance
improvement opportunities. Certain data collection and analysis
methods used on medical units can be tailored to psychiatric care; in
other instances, psych-specific measures can be employed. For
example, Baystate Medical Center is currently collecting data on
overnight wait occurrence in the ED for psychiatric patients. This will
serve as a quantifiable measure of limited availability of psychiatric beds
both in-house and in the region. Results of data collection such as this
help identify trends to be addressed through future initiatives.
In conclusion, RN case managers with strong utilization and medical
discharge planning experience can provide a unique perspective when
assigned to the psychiatric care team. This collaboration allows
psychiatric units to more effectively adapt to the changing healthcare
landscape, resulting in improved outcomes for patients.
Jan Limero, RN, ASN, BA, CCM, is a Hospital Case Manager at Baystate
Medical Center in Springfield, MA. She is currently responsible for
case management on the psychiatric and obstetrics units. She earned her
BA at University of Massachusetts and her RN from Cape Cod
Community College. Ms. Limero has 17 years of experience in the Case
Management Department at Baystate Medical Center, and 22 years of
experience in health care.