Harnessing Clinicians’ Top of License Expertise to Enhance Post-Acute Placements

Updated on April 8, 2024

Staffing shortages and throughput challenges are impacting all healthcare organizations, forcing care management (CM) leaders to re-evaluate their approach to care delivery. In a recent Kaufman Hall report, two-thirds of hospitals and health systems responding to a survey said “they have run at less than full capacity at some time over the past year because of staffing shortages.” 

Staffing and capacity issues not only can impact the patient’s care journey and health outcomes, but they also “have obvious implications for revenue,” the Kaufman Hall report concludes. Given the tight margins healthcare organizations struggle with today, the inability to operate at capacity can imperil the ability of hospitals and health systems to continue providing care. 

While financial limitations, the rising cost of labor, and a scarcity of qualified candidates preclude provider organizations from hiring full-time clinicians, there are options available to hospitals and health systems that can help them bridge the gap in post-acute care (PAC) delivery. 

One is to utilize support staff to decrease administrative work and keep the clinical registered nurse (RN)/social worker (SW) care manager closer to the patients and the multidisciplinary team (MDT). This can be accomplished by having purpose-built technology in place that allows CMs and support staff to seamlessly communicate with each other while enabling CMs to remain patient-facing.

Another approach is to leverage CMs’ clinical expertise in responsibilities that directly impact patient outcomes. CMs are often seasoned nurses with direct patient care experience that have transitioned to administrative roles within an organization. Unfortunately, they can spend far too much time sitting at a computer or standing in front of a fax machine pushing out referrals, tasks that could be performed by a clerical-level worker instead of a trained CM. Healthcare organizations must allow these experienced CMs to “practice at the top of their license” by redefining their roles and responsibilities to keep them as patient-facing as possible – and thus able to see the patient experience unfold from before and during hospitalization through post-acute care.

CMs should have a primary voice in the multidisciplinary team (MDT) in determining the appropriate next site of care for the patient based on their experience as well as their awareness of any financial restrictions with payers and regulatory requirements. In addition, CMs can play a critical role in training by helping educate new nurses on 1) patient throughput during multidisciplinary rounds (MDRs) and 2) the important role nurses play through activities of daily living (ADL) management. 

CMs also can educate physicians and ancillary services on ways to decrease throughput times. These may include deciding on the appropriateness and timing of physical therapy (PT) evaluations, determining whether clinical tests that are ordered but not necessary for discharge could be safely obtained by the patient as an outpatient, and selecting the optimal next site of care based on the patient’s unique needs and circumstances. Furthermore, CMs can provide feedback and experience to their accountable care organization (ACO)/population health counterparts who seek to build a productive and supportive PAC network.

A third way to bridge the gap in care management is by utilizing technology to provide patient choice while managing length of stay (LOS). This technology also should enable care managers to provide the patient with a variety of next site of care options, locations, and services, while balancing LOS. 

The benefits of data and a care coordination platform

Health systems today rely more than ever on partnerships to move patients to the right next site of care as safely and efficiently as possible. Technologies that enable PAC coordination and data-driven decision-making across a care network are at the center of those partnerships. 

By capturing and analyzing PAC placement performance data, CMs can determine where there are gaps in care and areas of improvement. However, rather than trying to solve every problem at once, CMs can use PAC performance data to identify a couple of areas where interventions would deliver the greatest impact in providing tactical solutions. 

The key is for CMs to look for trends in PAC provider responsiveness so they can collaborate on solutions. For example, having access to data around specific providers is necessary for objective analysis of the relationship and their ability to support the health organization. Other ways to use performance data:  

  • Allowing PAC providers to know how they are performing and where their trouble areas might be (this data should be made available to them)
  • For tracking throughput milestones, such as when an initial referral was sent and when the patient was booked to that facility 
  • To support internal partnerships. These can include the relationship between the hospital and the PAC network, compliance around regulatory requirements for choice, how to further engage the network, and how nurses and MDTs can work together to identify specific goals to decrease throughput. One goal may be completion of ADLs such as ambulation/out of bed to decrease the need for PAC services and to discharge the patient faster. Another may be encouraging nursing staff to move patients with confidence and decreasing the need for a physical therapist to be the first to get the patient out of bed.
  • To demonstrate how care management impacts the organization’s key performance indicators (such as LOS). Though CMs aren’t revenue-producing, their experience in managing care coordination and patient throughput can favorably impact an organization’s financial well-being. 

Health systems rely on a PAC network to move patients to the next best site of care. Without good data and insights, health systems will find it hard to know how their PAC network is performing, where to focus on improving performance, and how to implement the necessary changes. Capturing and analyzing PAC placement performance data can help uncover gaps in care and identify areas of improvement. With a scalable care coordination platform and the ability to leverage PAC data, hospitals and health systems can deploy innovative approaches to staffing issues, administrative burden, and PAC network optimization.

Gina Kidder
Client Outcomes Engineer. at ABOUT

Gina Kidder joined ABOUT in 2023 as Client Outcomes Engineer, with more than 30 years of experience in healthcare across nursing, HCIT implementations, and Care Management. Gina brings a unique combination of business operations and clinical experience to her role to provide health systems with real-time & ongoing insights to ensure their strategic plans around care orchestration & patient transitions are on-track towards success.

Before joining ABOUT, Gina became an RN after working on EMR implementations for Shared Medical Systems (SMS), and worked as a Trauma Nurse Clinician for a Level 1 Trauma Team in suburban Chicago. While completing an MSN, Gina transitioned to Care Management leading nurses and social workers in academic and community hospital settings prior to the challenging pandemic starting in 2019, and throughout. Gina is certified in Care Management through ACMA and an active member of the Illinois Chapter of ACMA.