COLLABORATIVE CASE MANAGEMENT
A Peer-Reviewed Journal for Case Management and Transitions of Care Professionals I S S U E
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J U LY
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In This Issue:
Recruitment, orientation, training and retention… everything you need to be successful
T H E O F F I C I A L P U B L I C AT I O N O F T H E A M E R I C A N C A S E M A N A G E M E N T A S S O C I AT I O N
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Bridging the Gap Between Theory and Practice: How Advanced Care Transition Simulation Can Help Debra McElroy, RN, MPH and Kathleen Ferket, MSN, APRN-BC
The healthcare environment is in a dynamic state of change, and case management is at the center of value-based care initiatives. Care managers must be knowledgeable about clinical, regulatory and payer requirements, all while developing rapport, building relationships and coordinating the care of complex patients. As health systems continue to expand, the case manager requires a working knowledge of the organization’s care continuum to plan the most optimal care transition for the patient. As a recognized leader in case management education, the American Case Management Association (ACMA) introduces Advanced Care Transition Simulation (ACTS), the first nationally recognized simulation training program for
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case managers. ACTS is focused on improving care transitions through simulation. ACTS uses a Learning Map© exercise with participants to ensure there is a solid, working knowledge of their own system of care. Nationally, inadequate care coordination and care transitions are responsible for $30-45 billion in wasteful spending.¹ Value-based payment (VBP) programs are increasing and promote the delivery of the right care, in the right setting, providing financial incentives for achieving quality standards and eliminating unproductive costs from the system. Valuebased payment models, like BPCI (bundled payment clinical improvement) and Accountable Care Organizations (ACO) align incentives to encourage collaboration
among disparate providers to achieve objectives. High-cost, complex patients often have suboptimal outcomes because of inadequate coordination. Improved hand-offs and coordination as patient’s transition from one provider to the next are key strategies in VBP programs. A well-structured VBP model draws attention to the full continuum of healthcare services. The ACTS program enhances understanding of care transitions and introduces the concept of longitudinal care coordination for complex patients. An exercise using the Transition of Care Standards© with the Learning Map, guides discussion about opportunities or solutions to improve communication regarding care transitions within their own system of care.
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LEARNING OBJECTIVES 1. Describe how simulation bridges the gap between theory and practice. 2. Review the mission and goals of the Advanced Care Transitions Simulation program and how you can apply it to your setting. 3. Identify how Transition of Care Standards can provide opportunities or solutions to improve communication within your system of care. BRIDGING THE GAP Simulation is an important methodology in bridging the gap between theory and practice in healthcare education and is now available for the case management field. The Advanced Care Transition Simulation (ACTS) program is focused on improving care transitions by assessing the performance of care management professionals in realistic patient scenarios, using standardized patients (SP). The ACTS program leverages unique, team-based simulations of patient scenarios to enhance care coordination and critical thinking. Participants are evaluated throughout the simulation on assessment skills, communication skills, transition planning, and documentation of the plan of care and collaboration. Traditional orientation and education in the acute care case management environment has been centralized within a department. Orientation may include shadowing opportunities with experienced case managers to observe their practice in the clinical setting with patients/families. Cross continuum roles for care managers have proliferated in ambulatory, community, and post-acute settings, but vary widely in preparation and skill sets. ACTS is tailored to address professional development and offers simulation experiences targeted toward care managers across the continuum. SIMULATION IN HEALTHCARE Healthcare simulation programs have spread to many parts of the country, including hospitals, medical and nursing schools, community college programs and clinics. Both high and low fidelity simulation have been used extensively within the domains of medicine, robotic surgery, dentistry and nursing education for the past 15 years.
Healthcare simulation is a technique that creates a situation or environment to allow persons to experience a representation of the real healthcare event for the purposes of practice, learning, evaluation, testing to gain understanding of human actions and systems.² Simulation is meant to replicate aspects of the real world in an interactive manner that allows learners to be immersed in the learning environment. In healthcare, we simulate to improve both the practitioner skill set but also to improve patient safety. Use of simulation continues to grow and high-tech simulation labs are becoming a standard of care at many academic centers. The American Case Management Association (ACMA) explored the concept of using simulation in case management education in a 2016 workshop and received positive feedback and suggestions from the over 200 participants. Subsequently, ACMA continued to refine the ACTS program, which was tested in five beta sites throughout 2018. We are indebted to the case management leaders and organizations who assisted ACMA in refining the ACTS program (see Table A). The ACTS program launched in 2019 and offers a turnkey approach to delivering case management education, using low fidelity simulation with standard patients representing realistic patient scenarios. Low fidelity simulation-use requires a patient care setting and minimal props to replicate the environment, but does not use monitors or high-tech equipment, mannequins or recordings which are fundamental to high fidelity simulation. The ACTS web-based portal offers a variety of resources (see Table B) and is designed to support implementation of the ACTS program at their organization. ACTS is a complimentary program to the Compass educational module program. Compass modules enhance case management
understanding of theory and knowledge, while ACTS fosters critical thinking, integration and the application of the case management skills into practice. ACMA’s cross modality of educational resources prepares today’s case manager, no matter their practice setting, to achieve the best patient outcomes in today’s value-based care environment. TABLE A: ACTS Beta Site Participants Baycare Health Inova Health Ohio State University Medical Center & The James Cancer Center Stanford University Medical Center Vanderbilt University Medical Center
TABLE B: ACTS Portal Resources Ten patient scenarios, which cross care setting: ambulatory, acute care, skilled nursing, acute rehab and pediatric Pre-simulation videos Educational resources: motivational interviewing, Teach Back, Longitudinal case management Pre and post test Links to CMS conditions of participation Glossary of terms Documentation samples Learning map, system of care sample
TABLE C: ACTS Anticipated Outcomes Staff engagement Improved relationships across care settings Staff retention or reduced voluntary turnover
Competency measures by participant, facility or system Potential for reduced orientation time Readmission reduction
Longitudinal care management practices
Improved understanding of care continuum
Improved patient experience with care transition questions
Improved patient safety associated with care transitions
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Patient safety is a key concept within the simulation environment. Simulation-based learning has demonstrated effectiveness in improving safety competencies in all healthrelated disciplines.⁴ Debriefing is an essential component of simulation that is used in
goals and the patient felt safe. In an actual patient encounter, case managers do not have the luxury to be able to say to the patient, “How do you think I did with your plan of care?” In ACTS, participants do have the ability to ask about their effectiveness
and experienced care management professionals and result in performance anxiety. The ACTS program reinforces a safe learning environment in the pre-simulation resources. Optimally, an ACTS assessor is positioned behind a two-way viewing area to lessen any concerns about observation throughout the simulation. CARE ACROSS THE CONTINUUM
nursing education. It can be defined as an activity that follows a simulation experience that is led by a facilitator where feedback is provided on the participants’ performance, all aspects of the simulation activities are discussed, and reflective thinking is encouraged. The review of the literature identifies significant learning occurs through discussion and reflection during debriefing.⁵ Fifty percent of hospital-related medical errors are attributed to poor communication during transitions of care.⁶ Debriefing with standard patients after the simulation allows for two-way feedback to determine if communication was clear, the care transition plan was understandable, met the patient’s
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and style. The ACTS educator/facilitator ensures all feedback is professional and respectful in accordance with the International Association for Clinical Simulation and Learning guidelines (INACSL). Any individual-directed coaching or review regarding opportunities noted in the simulation is completed in a private discussion setting. Maintaining a safe and supportive learning environment is key to a successful simulation experience. Clinical simulation experiences are associated with high levels of stress and anxiety that can leave learners unable to perform or inhibit learning.⁷ Being observed during a simulation may affect both new
Healthcare professionals who practice in one particular care setting may be unfamiliar with the requirements and nuances of care delivery in other settings, and this may contribute to fragmentation and poorly planned care transitions. The scenarios within the ACTS portal of resources include transitions from one care setting to another and offer the case manager the experience of coordinating care in an alternate care setting. A commitment to improve care transitions requires the case manager to adjust their viewpoint from an episodic to a longitudinal view. Patients transition across multiple settings, and it is necessary to ensure these transitions are as safe and coordinated as possible. This commitment also demands better communication, recognition of differences in staffing and resources, and the identification of information necessary to deliver optimal care in each setting. Expanding the case manager’s understanding of the care continuum is necessary for developing a longitudinal view of care management. This knowledge is essential for the case manager who coordinates care for complex patients, regardless of their practice settings.
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ACMA addresses this learning opportunity by using the Transition of Care standards and an ACMA Learning Map© during the ACTS program. Bringing care managers from across the care continuum to engage in simulation may enhance the skills needed to excel in a value-based model of care. ACTS TESTIMONY “Our organization embarked on this opportunity with the expectation that we would be providing a safe learning environment promoting the importance of quality care transitions,” said Pamela E. Andrews, RN, MSW, MBA, CCM, ACM at Inova Health System Case Management in Fairfax, Virginia. “The opportunity for our case management teams, home health nurses, transition case managers and subacute care partners to participate as one team further validates communication and drives the patient experience and the quality of care transitions. The program has exceeded our expectations. The ACTS experience has invigorated our practice and partnerships. As a case management leader, it has magnified the boxes/barriers we have inherently placed in the way of best practice, these ‘ah-ha’ moments are contributing to redefining how we practice, and our team members response has been priceless!” ACTS PROGRAM OPTIONS ACTS training options include either a train the trainer model, where an organization designated trainer can conduct ACTS training on site, or an ACMA-led ACTS program at their organization. Individuals designated to be ACTS trainers will participant in a full day of training at an ACMA designated simulation center to prepare them for conducting the ACTS program at their organization. Participants (trainees) enrolled in the program will receive ACTS portal access, which includes a pre-simulation video, review materials and a pre-test. Participants are required to complete all pre-simulation materials prior to attending the simulation workshop. Evaluation is based on pre and post testing, assessment of practice during the simulation, and documentation associated with the plan of care. The simulation assessment tool evaluates observed behavior and performance in the following categories: education,
professionalism, assessment, care coordination, transition management, compliance/documentation, and utilization and resource management. Reports are automatically generated within the ACTS portal. Scoring is available for review by overall organization, individual facility or individual participant. These reports are useful in identifying additional
for a case manager, it is documented that it may cost anywhere from $97,216 to $104,440 to replace a nurse.⁹ This cost does not account for the clinical experience, regulatory and payer knowledge required of a case manager. It is more difficult to reference the cost of a social worker in the case manager role, although estimates about training a new social worker costs about $54,000,
educational needs and will meet requirements of regulatory agencies requesting ongoing educational records to demonstrate competency.
according to the Texas State Committee on Finance.¹⁰ This may vary based on years of experience and geographic location. Case managers are aging with nearly 44% over the age of 55.¹¹ This may contribute to additional vacancies and the need to focus on both recruiting and retention in a now very competitive case management environment. Investments in educational and professional development may foster staff satisfaction and promote organizational retention.
ACTS PROGRAM OUTCOMES There are many studies that demonstrate the effectiveness of healthcare simulation for professionals and patients alike.⁸ Currently, there are no studies specific to outcomes associated with case management simulation education. The ACTS program anticipated outcomes are based on applicability to related research in the healthcare simulation field. Data will be collected as organizations implement ACTS to further identify the impact on patient safety, improved care transitions, reduced readmissions, improved patient experience and improved healthcare relationships across the care continuum. It is postulated that enhancing longitudinal care management practice/knowledge will positively impact value-based programs, such as Bundled Payment Clinical Improvement and ACO models of care. While there is little evidence in the literature to estimate the cost of turnover
CONCLUSION The use of simulation as a required component of case management training has the potential to transform orientation, professional development and patient outcomes. ACMA is collecting pre and post ACTS implementation data to identify and monitor select outcomes associated with the ACTS program. Future publications will continue to highlight the return on investment in case management education and development programs. Additional information on the ACTS program can be obtained here.
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ABOUT THE AUTHOR Debra McElroy, RN, MPH, is Senior Vice President for Practice Development and Education at the American Case Management Association. Kathleen Ferket, MSN, APRN-BC, is Senior Consultant of Transitions of Care and Simulation Programs at the American Case Management Association. REFERENCES 1. Health Policy Brief: Care Transitions, Health Affairs, September 13, 2012. Numbers adjusted to 2018 dollars using Consumer Price Index for Medical Care, https://fred. stlouisfed.org/series/CPIMEDNS. 2. Lopreiato JO, Downing D, Garmmon W, et al; Terminology & Concepts Working Group. Healthcare Simulation Dictionary. Rockville, MD: Agency for Healthcare Research and Quality; 2016. AHRQ Publication No. 16(17)-0043.
3. Harder, N (2018) The Value of Simulation in Health Care: the obvious, the tangential, and the obscure. Clinical Simulation in Nursing, editorial. Elsevier, 15, 73-74. 4. Boet S., Bould D., Fung L., et al; (2014) Transfer of learning and patient outcome in simulated crisis resource management: a systematic review. Canadian Journal of Anesthesia, 61, 571-582. 5. Pivec, C., (2011) Debriefing After Simulation: Guidelines for faculty and students. Scholarly project, St. Paul, Minnesota. 6. Improving Care Transitions: Optimizing Medication Reconciliation, March 2012, American Pharmacists Association & American Society of Health System Pharmacists. 7. Tyerman, J., Luctkar-Flude, M., Graham, L., et al; (2019) A Systematic Review of Health Care Pre-simulation
Preparation and Briefing Effectiveness. Clinical Simulation in Nursing, 27, 12-25; Elsevier, Inc. 8. Walsh, C, Lydon, S, Byrne, D, et al; The 100 Most Cited Articles on Healthcare Simulation. Society for Simulation in Healthcare. 2018, 13, 3, 211-220. 9. https://www.beckershospital review.com/finance/will-2018-be-the-yearhealthcare-addresses-its-turnoverproblem.html 10. h ttps://www.governing.com/ columns/smart-mgmt/gov-social-workersturnover.html 11. https://www.reliasmedia.com/ articles/134694-experts-market-casemanagement-to-younger-hc-professionals Jones, C. (2008) Revisiting Nurse Turnover Costs. Journal of Nursing Administration, Wolters Kluwer Health; 38: 1, 11-18.
To learn more about the American Case Management Association (ACMA) please visit: acmaweb.org To learn more about ACTS please visit: acmaweb.org/acts If you'd like to become a member of ACMA visit the website below to learn more about member benefits: acmaweb.org/membership