C O L L A B O R A T I V E C A S E M A N A G E M E N T

A Medical Director’s Perspective

Improving Case Manager-Physician Communications
By Michael Werdmann, MD

Over the past decade medical cases have become increasingly complex. Because of this, the clinical care team responsible for a single patient
often includes several different physician specialists, consultants, nurses, therapists, dieticians, and pharmacists. It is difficult to overstate the
importance of clear communication between members of the healthcare team when there are so many specialized members on that team.

Case management is a relatively new addition to the hospital expanding population. Healthcare systems overall no longer have an excess
setting. Not all physicians clearly understand case management’s role of staffed and ready beds available. Because of this, it is increasingly
and functions. This can, therefore, increase the likelihood of important that all physicians internalize the responsibility of stewardship
miscommunication between case managers and physicians – situations of this scarce resource. A patient who occupies an inpatient bed longer
where logical reasoning on the part of one is wrongly perceived and than medically necessary delays care for the next patient and reduces
misunderstood by the other. overall community access to care.
Understanding the fundamental SBAR report to physician about a critical situation
When beds are unavailable, patients
communication barriers that can SITUATION suffer by being diverted in an
I am calling about <patient name and location>
arise between case managers and The patient’s code state is <code status> ambulance to another facility,

physicians will lead to strategies for
overcoming these challenges,
decreasing the likelihood and
frequency of miscommunications.
This article presents four strategies
to enhance communication between
case managers and physicians.
S
The problem I am calling about is ___________________________________________.
I am afraid the patient is going to arrest. potentially delaying care, or by
I have just assessed the patient personally:
Vital signs are: Blood pressure ______/______, Pulse _______, Respiration ______ and temperature _______ boarding and receiving portions of
I am concerned about the:
Blood pressure because it is over 200 or less than 100 or 30 mmHG below usual their inpatient care in hallways or
Pulse because it is over 140 or less than 50
Respiration because it is less than 5 or over 40 the emergency department.
Temperature because it is less than 96 or over 104
BACKGROUND
There is increased recognition
The patient’s mental status is:
Alert and oriented to person place and time
in the medical community that
Confused and cooperate or non-cooperative
Agitated or combative
a community-oriented systems
Lethargic but conversant and able to swallow
Stuporous and not talking clearly and possibly not able to swallow
view of healthcare resources is an

RECOGNIZE DIVERSE
VIEWPOINTS
Case managers are responsible
for systems-based outcomes.
According to findings from the 2005
ACMA National Case Management
B
The skin is:
Comatose. Eyes closed. Not responding to stimulation asset to physician decision-making.
Warm and dry
Pale
Evidence of this can be seen in that
Mottled
Diaphoretic
the ACGME (Accreditation Council
Extremities are cold
Extremities are warm
for Graduate Medical Education,
The patient is not or is on oxygen
The patient has been on ______ (l/min) or (%) oxygen for _____ minutes (hours) the oversight organization
The oximeter is reading ______%
The oximeter does not detect a good pulse and is giving erratic readings responsible for physician medical
education) defines a series of six

Survey1, case managers listed length
of stay, cost per case and avoidable
days as three of the top nine key
outcome measures they consider
important. These responsibilities
A
ASSESSMENT
This is what I think the problems is: <say what you would like to see done>
The problem seems to be: ■ cardiac ■ infection ■ neurologic ■ respiratory competencies that are the goal of
I am not sure what the problem is but the patient is deteriorating
The patient seems to be unstable and may get worse, we need to do something graduate medical education
RECOMMENDATION (residency). One of these is Systems-
I suggest or request that you: <say what you would like to see done>
Transfer the patient to critical care Based Practice, defined as an

R
Come to see the patient at this time

define the viewpoint of case

Talk to the patient or family about code status
Ask the on-call family practice resident to see the patient now awareness of and responsiveness to
Are any tests needed:
management. Bed occupation Do you need any tests like CXR, ABG, EKG, CBC, BMP? the larger context and system of
Others?

without medical necessity equates If a change in treatment is ordered then ask:

How often do you want vital signs?
health care and the ability to
to denial of reimbursement, and any
How long to you expect this problem will last?
If the patient does not get better when would you want us to call again? effectively call on system resources to
delay in care equates to increased provide care that is of optimal value.2
length of stay and decreased system While incorporating a systems
EXHIBIT A – An SBAR template of clinical communication between a nurse and
productivity and revenue. viewpoint into physician education
a physician. This template was developed by Kaiser Permanente of Colorado. 3
In contrast, physicians are is movement in the direction of
trained to focus on individual patients. It is unlikely that the three systems-based care management, a physician approach to care and a case
outcome measures cited by the case managers would appear in a survey management approach remain very different. Understanding these
given to physicians. They are likely to prioritize individual patient issues divergent viewpoints, case managers must take caution in communications
and outcomes, even at the expense of systems outcomes. This can, at to avoid the perception as “UR Police” – the perception that they are
times, lead to a desire on the part of the physician to keep a patient in the focused on revenue rather than patients. Case managers can make clear in
hospital who does not meet medical necessity. This is even truer for their communications that their goal is to find the best place for the patient
community physicians who spend a small percentage of their time in the at the present time, equally balancing system outcomes and patient care.
hospital setting. Additionally, there is often a mis-alignment of incentives
since the physician may be paid additional money for additional days or OPTIMIZE TIMING AND METHOD OF INTERACTION
services, even if the hospital is denied or receives no added payment. Communications should be strategically timed and placed to
Healthcare as a community resource is increasingly scarce. A steadily minimize interruption. Case managers should try to communicate while a
decreasing number of inpatient beds are available to care for an aging and physician is in the hospital setting and on unit. This is especially important,

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 w w w . a c m a w e b . o r g
although often difficult, for community doctors who spend a small portion
of their time in the hospital. Calling these doctors at their office will almost
invariably cause an interruption in patient care.
Face to face communication also allows a relationship to develop.
Rapport, and a history of positive past interactions, creates a positive
foundation for present and future communications. Positive interaction is
more likely and attainable in face-to-face contact than via phone or email.
DEVELOP AND MAINTAIN CREDIBILITY
Any communication is necessarily influenced by previous experience,
especially recent interactions. An unpleasant interaction becomes the
context for future communications. Ideally, both parties are able to move
past a negative experience, and not assume that future interactions will be
negative – but in reality this is difficult and rare.
It is important, therefore, that case managers maintain their
credibility with physicians. Complacency with other hospital staff
members can pose a threat to this credibility. Physicians, especially those
with community practices, must necessarily glean information from the
perceptions of other staff members, such as chart notes and
conversations with nurses and therapists. Case managers, similarly,
receive much of their patient information from these sources – people
with which they have frequent and collegial interaction. Because of the
relationships that develop from daily interactions with coworkers, there
can be reluctance to challenge the perceptions of these staff members
with the level of skepticism that would normally be applied to subjective
perceptions of patients and patient data. This can lead to the acceptance
of inaccurate perceptions and their subsequent communication to a
physician as solid information. In order to maintain physician credibility,
case managers need to maintain a professional level of skepticism.
PACKAGE INFORMATION
In medicine there is a tendency to relate important information by
storytelling – relating a narrative rather than concisely stating the request
or recommendation. The danger presented by the lack of precise
communication has been recognized in other fields, such as military
communications. In response, the military developed the SBAR tool to
improve communication packaging. SBAR stands for Situation,
Background, Assessment, and Recommendation. This tool provides a
template for precise communication. After successful implementations
in the military and aviation, this tool is being adopted into healthcare.
In September 2005, Bridgeport Hospital launched an initiative to
reduce length of stay by one full day. This initiative included retention of
a consulting firm who assisted in a review of the case management
department and additional training for case managers. They presented the
SBAR format to the hospital administration as a potentially useful tool.
Because the SBAR template had proven success in situations, such as
aviation, that demand high reliability, it was incorporated into this training
as a tool to enhance the communication effectiveness.
To implement the SBAR tool, Bridgeport Hospital held two training
sessions for the case management staff. These involved an introduction
to the technique and multiple role-playing exercises. These exercises
juxtaposed the normal methods of communication with the same
information communicated using the SBAR template, demonstrating
the tool’s effectiveness. Practicing using the tool in a role-playing
situation was extremely helpful in increasing the staff’s comfort level
with the template. The eventual goal was to embed the SBAR pattern
into staff communication.
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Since so much of the daily communication of case managers is with
resident physicians and hospitalists, each of these groups also received
basic SBAR training. This training is consistent with the charge of the
ACGME for systems- based practice for residents.
In reviewing the project status, SBAR training has improved
communication between case managers and physicians and we have had
good progress toward the goal of LOS reduction. However, “hardwiring” of
new communication patterns has not occurred to the extent we would
have hoped. We believe that some part of the failure is the lack of training
of all providers involved in communicating.
Based on the experience of Bridgeport Hospital, the greatest benefit
can be reaped from implementation of the SBAR tool by training
information receivers as well as information givers – in this case, physicians
as well as case managers. There is a natural tendency for communication
patterns to lapse into previous habits, so information receivers who are
committed to using the format enforce the expectation that information be
packaged in this streamlined template.
Educating medical staff about this type of hospital initiative, however,
can prove an ongoing and daunting challenge. At Bridgeport Hospital we
have faced challenges in initiatives related to publicly reported measures,
medication reconciliation, prohibited abbreviations, and many other
similar issues that require new behavior from the medical staff. Finding
means to educate the large pool of community physicians has often
proven difficult.
In the case of SBAR, we were fortunate to be able to do some limited
training of the “captive” resident physicians and physicians having a large
percentage of their practice in house, such as hospitalists and physicians
with large patient panels, who we believed should be more receptive to
such training and would be willing to commit the time. Communication to
the larger community-based medical staff was a short presentation at the
general meeting of the medical staff and through published materials.
Materials included a specific memo and articles in the monthly medical
staff newsletter.
Communication in healthcare will remain a critical challenge.
Developing practices and structures to enhance communication between
members of the healthcare team can have far reaching effects on both
clinical care, such as increasing patient safety and reducing medication
errors, and systems outcomes, such as LOS reduction and decreasing
discharge barriers. Implementing a focus on communications can prove a
valuable tool for overall organizational improvement.
1. American Case Management Association. “National Case Management Survey.”
2005.
2. Accreditation Council for Graduate Medical Education. “Competencies.”
ACGME Outcome Project. September 2006. <http://www.acgme.org/outcome/
comp/compFull.asp>
3. M. Leonard, S. Graham and D. Bonacum, Kaiser Permanente of Colorado.
“SBAR Technique for Communication: A Situational Briefing Model.” Insititute
for Healthcare Improvement. 2004. September 2006. <http://www.ihi.org/IHI/
Topics/PatientSafety/SafetyGeneral/Tools/SBARTechniqueforCommunicationASit
uationalBriefingModel.htm>
Michael Werdmann, MD, has been the Chairman of Emergency Medicine
since 1989 and Medical Director of Case Management since 2005 at
Bridgeport Hospital in Bridgeport, CT. He earned his MD from the University
of Cincinnati School of Medicine, and is board certified in Internal Medicine,
Pediatrics and Emergency Medicine.