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A Medical Director’s Perspective

A Case Study of Case Escalation
By Cheryl L. Phillips, MD, AGS, CMD

Case escalation is for many a daily reality of providing medical director support to a case management service. It can be come a costly effort –
both in time and relationships with physician colleagues. In this column, we take a look at the process used by a 700-bed, urban academic
medical center to see what application it may offer to other institutions.

CASE ESCALATION AT MIDWESTERN MEDICAL CENTER • Though it has not been necessary, the escalation protocol dictate
Midwestern Medical Center* is a 700 bed hospital located in a large that issues not resolved through consultation with the physician
urban setting and affiliated with a medical school. The case advisor are referred to the attending physician’s department
management service employs two part- Chairperson for resolution.
time physician advisors which allows
This medical center reports that
the physicians to maintain a practice in
since the introduction of the case
addition to their employed role. The This hospital’s process facilitator into the escalation protocol,
complement of case management staff
the number of cases escalated to the
includes “care facilitators” who are the
first step in the escalation process. Care
demonstrates the physician advisor per day have fallen
from between 25 and 30 to just five.
facilitators are RN case managers who
have the responsibility to identify importance of having a REVIEW OF THE PROCESS
problems or barriers to patient This hospital’s process
throughput. clear and defined set of demonstrates the importance of
Case escalation is as varied as the having a clear and defined set of
patients and the physicians who care for
them. However, at Midwestern Medical
criteria and action steps criteria and action steps for case
escalation. All too often case
Center, there is a basic protocol that
successfully guides the majority of cases. for case escalation. All too managers are left with a vague
directive of “just call the physicians
• Administrative barriers to advisor when you get into trouble or
discharge such as test or therapy often case managers are left need some help.” This lack of clarity
scheduling are escalated to the can create confusion, frustration and
care facilitator. Her role is to with a vague directive of missed opportunities for engaging the
negotiate with the appropriate physician advisor early in the course
department by sharing the “cost”
of delaying a discharge solely for
“just call the physicians before tensions rise and conflicts
emerge. Although not described in
scheduling reasons. this case study, another essential
• A patient that does not meet advisor when you get into component is for the medical staff
inpatient criteria (InterQual criteria leadership to understand and support
are used in this case) is first discussed trouble or need some help.” the role of the physician advisor,
by the care facilitator with the which then allows for additional
attending physician. If differing views clarity when and if the issue is not
of the clinical status of the patient or resolved with the initial interaction
the feasibility of a safe discharge persist, the case is escalated to the between the attending MD and physician advisor.
physician advisor for peer-to-peer discussion of the case. The role of the physician advisor, when both defined and
• Occasionally a physician makes clear that he or she is not open to communicated to the team, can serve to support the case management
input from a case manager on any aspect of a patient’s care. In this process, improve attending physician engagement with the case
circumstance, cases are immediately escalated to the physician management team and, most importantly, lead to improved and more
advisor to avoid unnecessary antagonism or delay. efficient care.

*pseudonym
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