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Oncology Case Management Across the Continuum of Care

by Amelia Williams, MSW

Grady Health System, a 953 bed inner city, public safety net hospital, developed a cancer center in 2003 to address health disparities and cancer
health rates in a largely minority population. Collaborative case management was seen as essential to optimizing treatment outcomes in this
vulnerable population. Experienced oncology social workers and nurses formed the Oncology Care Management department to address the
needs of patients across the inpatient and outpatient continuum. Traditional social work intervention gave way to a case management approach,
when reducing missed appointments and gaps in chemotherapy treatments became a focus of concern. The missed appointment rate became
critical for the Oncology Clinic when up to 50% of patients were “no show” for appointments; a rate consistent with other clinics in the hospital.
Missed appointments compromised treatment outcome and quality of life, and escalated the cost of care. Most disturbingly, prolonged delays in
treatment allowed for the advancement of disease and increased the likelihood of prolonged hospitalizations and death.

Three interventions, involving a collaborative sharing of medical and
psycho-social assessment information by the case management staff were
instituted in an effort to impact this problem.
1. Appointment reminder calls, which included brief psycho-social
assessments, are made the day before a patient’s first oncology clinic
appointment,
2. Daily case management team meetings are held with the inpatient and
outpatient oncology social work case managers and the inpatient
oncology nurse case manager. These meetings focus on medical and
psycho-social factors impacting discharge planning and treatment
compliance.
3. An Oncology Inpatient Discharge Communication Book is maintained
in the Medical Oncology Clinic to denote oncology in patient
discharges and oncology outpatient clinic appointments.
APPOINTMENT REMINDER CALLS
Telephone reminder calls, made the day before a new patient
appointment to the Medical Oncology Clinic, provide the outpatient
oncology social work case manager with the opportunity to complete a brief
psycho-social assessment while reminding patients of the next day’s
appointment. Information from these calls often provides patients with the
opportunity to voice concerns. Some of the most frequent concerns include:
• treatment or treatment side effects;
• difficulties experienced while navigating through the hospital system
and the impact of having to make special arrangements to allow family
members to accompany them;
• reluctance to keep appointments related to past experience
where system errors in scheduling resulted in unnecessary loss of
hours at work;
• concern about staff reaction to reluctance to proceed with treatment
and the need for reassurance that feelings about treatment and the
need for information regarding diagnosis, prognosis and the risk and
benefits of treatment will be respected;
• important family events which pre-empt medical appointments for
cancer care.
One recent example highlights how different a patient’s perspective might
be from that of a clinician focused on treatment who believes that treatment
must certainly be the most important thing to any patient. A patient with
metastatic prostate cancer expressed his intent to miss his new patient
oncology appointment in order to share in the family’s experience of
escorting his daughter to college. A critical life passage that did not need to
be a barrier to treatment once its importance to the patient was voiced and
understood by the care-giving team.
Information from these calls also provides the social work case manager
with information of significance to treatment planning and clinic scheduling.
It is frequently revealed that some patients live in non-traditional settings
with limited support for a rigorous treatment plan (shelters, rooming
houses); that some have made changes in their treatment plans (decided to
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proceed with hospice) and that some have died.
This information is communicated by the outpatient social work case
manager to the outpatient team both in writing and in informal discussions
with the outpatient oncologist and the outpatient oncology team nurses.
These communications influence appointment scheduling, pre-counseling
with patients and treatment plan modifications. They also identify patients
with significant barriers to care and potential hospitalization. A three-month
review of appointment compliance among new oncology patients who
received pre-calls by the oncology social work case manager revealed a 78%
compliance rate, up significantly from the previous 50% rate.
DAILY CASE MANAGEMENT MEETINGS
The second intervention that is utilized to decrease missed appointments
and gaps in treatment involves participation in daily case management
meetings. These meetings, with the inpatient and outpatient social workers
and the nurse case manager are held to discuss current and discharge needs
of oncology inpatients. Patients housed on the oncology unit are hospitalized
for chemotherapy treatments or for complications related to cancer or
cancer care. A small number of patients are newly diagnosed with cancer
during their hospitalization.
Communication between the inpatient social work case manager, the
outpatient social work case manager and the inpatient nurse case manager
focuses on psycho-social barriers to care such as patient support systems,
adjustment to illness physical functioning, medical needs, patient education
and understanding of their diagnosis. Discharge planning for patients takes
into consideration factors that may affect treatment compliance. Discussions
of inpatient psycho-social needs often lead to sharing of outpatient support
services with hospitalized patients. Sharing of these services significantly
decreases stress associated with hospitalization and cancer treatment and
increases patients’ receptiveness for treatment. Several case examples
illustrate this well:
Mr. Smith, hospitalized for PEG tube placement and chemotherapy
was distressed and anxious to effect a premature discharge as his
housing eviction hearing was scheduled to take place during his
hospitalization. An attorney with the Legal Aid Cancer Initiative
Program, providing legal consultations for patients in the outpatient
Medical Oncology Clinic, was able to consult with Mr. Smith and effect
a continuation of the eviction date thereby, preventing a premature
discharge, and reducing the stress related to an immediate eviction.
Mrs. Jones, hospitalized for chemotherapy for acute myelogenous
leukemia and concerned about loss of hair as a side effect of treatment,
was able to attend the Look Good Feel Better Program, offered in the
outpatient Medical Oncology Clinic.
Ms. Johnson, newly diagnosed and anxious due to the long
hospitalization required by her treatment, joined the outpatient Art
Therapy Class. Ms. Johnson benefited not only the therapeutic nature
 C O L L A B O R A T I V E
The Way I See It: A CEO Perspective (continued from page 3)
dealt with in a fair and consistent manner. Physicians are no different from the
rest of us – change is difficult. However, continuous improvement and
therefore, change, is the rigor for a good case management program to be
successful.
Circulating through all aspects of the triangle is education – ongoing
education of physicians and case managers. Our case managers have
educational opportunities about appropriate patient progress, care planning
and documentation of problems. Our medical staff is educated about what
case management is: the case management process, goals and expectations of
physician participation in a successful program. Case management is care
coordination. It ensures consistent quality care to all patients, regardless of
Capturing Return on Investment for Case Management Services (continued from page 5)
VISIBILITY: THE BOTTOM LINE
Savings From Within
As case managers, our focus is appropriately outward – how can we improve
patients’ care, improve processes and increase the organization’s opportunity
for both cost saving and revenue. But, there is also opportunity when we look
inward at our department. The reduction of staff turnover in case management
is just such an opportunity. Community Health Network calculated what it
costs to bring in a new RN case manager and a new social work case manager.
The amounts are staggering: $45,962 and $38,970, respectively. These numbers
include everything — advertising the position, initial work by HR, checking
references, doing interviews, and the lengthy training and orientation
required before the new person can begin working independently. Clearly, it is
financially prudent to keep these professionals on staff as long as possible.
Community launched a multifaceted effort to retain case managers. A
significant budget was dedicated to newsletters, recognition events, and
various other retention efforts. Results demonstrated the return on this
investment. In one year, there was a 20 percent decrease in case management
turnover rate, which saved the network nearly $850,000.
Oncology Case Management Across the Continuum of Care (continued from page 6)
of the art activity, but also from opportunity to discuss her fears and
feelings about her new role as a cancer patient with other cancer patients
in the group.
INPATIENT ONCOLOGY DISCHARGE BOOK
The third component of collaboration, and a by-product of information
from the daily case management meetings, is the Inpatient Oncology
Discharge Book. The discharge book is kept in the outpatient Medical
Oncology Clinic team room and is used to track patient flow between the
inpatient and outpatient areas. Special attention is focused on outpatient
follow-up of patients hospitalized for chemotherapy, special procedures to
support treatment, complications associated with treatment and patients
diagnosed with cancer during hospitalization. The discharge book can be used
by all clinic staff to learn the reasons for admission, discharge dates, outpatient
clinic follow up dates, current telephone numbers, ongoing or planned
radiation therapy and special circumstances of discharge (shelters, personal
care homes, hospice, changes in environments for care and treatment plans).
The Inpatient Oncology Discharge Book also provides a record of whether
scheduled outpatient appointments are being kept and facilitates early
intervention if necessary. The written communication often serves as a
reference to clarify discrepancies in appointment scheduling thereby, helping
to keep patients on schedule for treatment and follow-up. A review of patients
C A S E M A N A G E M E N T
payor mix or ability to pay. We educate our medical teams to provide the same
standard of care for all patients.
Perhaps the biggest challenge is creating a new case management culture.
The responsibility to do this rests ultimately with the CEO and senior
management. In my view, the Four Es framework provides a context that
supports a proactive care coordination effort.
Andrew B. Leeka has been president/CEO of Good Samaritan Hospital (Los
Angeles) since 1996. He holds an MPH from the University of California Los
Angeles, an MBA from California State University Northridge and an MA in
Organizational Behavior from Philips Graduate Institute.
The Bottom Line
Community was successful is demonstrating to both their
administration and board very significant savings in five areas:
CDMP recovery, avoided delays, conversions recovery, appeals
recovery, and length of stay/DRGs. Their bottom-line total for the
last fiscal year: $5,750,000 recovered by case management. While the
revenue potential is dependent on the size of the hospital or health
system, being able to effectively collect and report such information
is a step toward recognition as a revenue-producing department
rather than an overhead department or cost center. And that is return
on investment.
Vickie Alexander Knight, is director of Case Management at Community
Hospitals of Indiana, in Indianapolis, IN. Her 30-year career in healthcare has
encompassed both the hospital and the payer side, home health, and consulting.
She holds an ADN from the University of Indianapolis and a BS in health
management from the College of St. Francis, Joliet, IL. She has served on the
Indiana Congress on HealthCare.
who were discharged from the inpatient oncology unit and who kept their
outpatient appointments to medical oncology clinic revealed 62 % compliance
during a 4-month period from May through August.
This venture in collaborative case management illustrates many benefits of
an integrated and collaborative case management system:
1. Shared comprehensive psycho-social assessments along the continuum
of care and the impact these assessments may have on the team
commitment to patient care.
2. A mechanism to address and track compliance issues and behavior,
allowing early intervention when patterns are identified.
3. Advanced familiarity with patient concerns and barriers to compliance and
the opportunities they present for corrective interventions, improvements
in systems problems and improvement in patient satisfaction.
4. Team connectedness and purpose around a common goal.
5. The impact of collaborative case management on patients’ appointment
and treatment compliance.
Amelia Williams has been the oncology social work coordinator at Grady Health
System, Atlanta Georgia for 4 years. A MSW graduate of the University of
Wisconsin School of Social Work, Madison, Wisconsin, she has 23 years of
experience as an oncology social worker and is a member of The Association of
Oncology Social Workers.