When it comes to coordinating care for patients at UP Health System — Marquette, that responsibility falls to the care management department. It’s diverse responsibilities that make care management a vital part of the hospital’s day-to-day tasks.
Care management for patients includes:
- Reviewing cases for medical necessity
- Ensuring payer authorization from provider offices prior to surgical procedures
- Focusing on quality
- Contacting insurance companies to obtain authorizations for admissions.
- Reviewing the patient’s admission status, which is an integral part of Utilization Review
- Discharge planning
“Our care management team has a diverse set of skills to care for the whole patient,” said Julie Giackino (BSN, RN), Director of Care Management at UPHS. “We truly look at the whole picture for the patient and the institution. Our goal is to make sure we’re getting it right every time.
UPHS — Marquette’s average daily patient census is between 130-150. Every patient has a case manager review the patient’s case to make sure the person is receiving the right level of care — whether that means the patient should be in the ICU, a step-down unit or in a telemetry bed. Then they review the status, such as should the patient be deemed inpatient, observation or outpatient.
“Every three days, if the patient is still here, we go through and review if they continue to qualify being here,” Giackino said, “looking and seeing if we’re doing what we need to be doing. We, in turn, communicate with the physicians and let them know if their patient meets medical necessity or advise a provider that the patient in observation actually qualifies for an inpatient status.
“When patients come in, we’re working with the admission staff and making sure the patient is in the correct status. With discharge, we’re also working with the billing staff to make sure we’re billing the stay correctly.”
The care management department also coordinates the treatment options with various therapies including physical, occupational, speech, respiratory and wound care, as well as working with dietitians and the pharmacy. This allows a clear understanding of what the patient will need upon discharge.
It’s here when the interdisciplinary team decides if the patient is healthy enough to return home, will need additional services or be admitted to a nursing facility.
“We often have difficult conversations with patients and families concerning what is next for them, what their needs are and then we facilitate that once a patient has signed a preference letter as to where they want to go,” Giackino said. “Then we send a packet of information to the facility or agency and make sure that they’re willing to accept the patient.”
With UPHS being a regional medical facility, the care management department gets referrals from all over the UP and northern parts of Wisconsin. On occasion, the department will work with court systems in order to get legal guardianship for patients.
“I think we’re truly the heart of finding that balance for the patient,” Giackino said, “making sure they get all the care they need and making sure the institution is providing the right level of care every day for that patient. When that patient is ready to go, we facilitate them getting discharged from the facility.”
Facilitating care for a patient once they walk through the doors up until they leave means the care management department is with the patient and their families every step of the way. The natural interaction leads to connecting with patients on a personal level.
“It’s very rewarding because you’re asking people what they want, what they think they need and advocating for them at that level,” Giackino said. “Sometimes it’s having very difficult conversations when you’re working with loved ones who promised to not put someone in a nursing home and they’re crying because they know they cannot safely care for their loved one anymore. You’re walking that walk with them. It can be very emotionally draining, but it’s valuable to find what that person needs in order to be safe when they leave here.”
With the various daily tasks, it’s not difficult to see the commitment level of the care management department invests into the patients and hospital to ensure the best outcomes for both parties. Then there’s this: in the last two years, no one from the care management department has called in sick on the weekend, and out of 3605 scheduled shifts over the last year, there were only 21 call-ins or 0.58%.
“That’s how dedicated they are; they’re awesome,” Giackino said of her staff. “This is our community, our family, our neighbors, our friends that we are caring for. The most rewarding part is that the people we care for could be our family. We want to get it right for them.”