Nursing case management. Resolving the DRG paradox.

Nursing Case Management as described here was developed in less than ideal conditions: a full census, a 30 per cent increase in patient volume over five years, a nursing shortage, no grants or outside funding, no clinical specialists or clinical ladder, and no computerized documentation system. No more staff or salary was added as we focused our attention on the new tools, roles, and structures necessary to achieve cost and quality outcomes. However, nursing case management has worked because of some very key elements: 1. A firm commitment to the belief that staff nurses must be accountable for the outcomes of the care that they have planned, given, managed, and continuously evaluated. 2. A combination of top-down organizational development strategies with excellent staff nurse involvement at each juncture. 3. Negotiation and collaboration with physicians and hospital administration at key turning points. This includes the relentless articulation of patient-centered care. 4. A willingness to learn and risk together as a whole department--across levels, across specialties. This includes a constant balance of moving from concrete examples and problems to reconceptualizing the issues. 5. Listening, responsiveness, humor, and acknowledging contributions of everyone. More than any other principal, the case manager must be a central caregiver to a patient to ensure cost/quality outcomes. Otherwise case management only adds to the cost of health care by adding another level of bureaucracy. Nurses have always managed the care of patients, but to stay effective and committed, they need to take increased authority in their patients' entire episode of care and develop formal collaborative practice groups. In other words: "Prospective payment has changed the health care product from a day of care (or a visit) to an entire case or episode of illness. More than just a new way of paying for care, it has changed our way of planning, managing, and thinking about health care." Looking at the future entails understanding our business, and then changing our practice patterns for the change in the times. Necessity will foster invention; Nursing Case Management provides a model and technology for innovation.