- Email: [email protected]
Making case management a priority in the subacute setting
Making OESO Managornent A Priority In Tho Subacuto Setting by Mary Flannery,RN, CRRH,CCM
s the health care environment continues to evolve, more skilled-nursing facilities are developing subacute care programs to provide services for the increasing numbers of patients for w h o m acute hospitalization is no longer appropriate. Administrators generally understand that case management plays an important role in directing positive outcomes as well as controlling costs. This results in their support for systems and procedures that integrate the philosophy of managing care and financial resources within the entire care team. They have
learned that isolating case management responsibilities within a single individual (the case manager) can lead to inappropriate planning and resource utilization, resulting in a treatment team that becomes frustrated with what appear to be conflicting forces - - internal and external - - directing patient care.
position in providing intense, yet costeffective, short-term medical and rehabilitation services has opened the door to new reimbursement sources. More private insurers than ever before now cover subacute services, requiring close coordination between facility care teams and external case managers.
Significant differences in reimbursement systems finCher increase the importance of integrating case management into a subacute care unit's care planning and treatment processes. Subacute care's
The two major reimbursement sources for subacute care are Medicare and managed care insurers. Each has a distinct approach to treatment and reimbursement.
DichotomyOf Systems
OCT/NOV/DEC 1995 9 TOM 61
Currently responsible for the larger percentage of subacute care's reimbursement, Medicare operates according to stringent regulations that govern both the provision of care and reimbursement for qualifying services. It is within this system that most clinicians have become familiar and comfortable in basing treatment protocols. Managed care insurers, on the other hand, typically focus on medical necessity, with an emphasis on moving patients efficiently and cost-effectively to the next level of care. This challenges providers to identify and procure resources to address safety, architectural, and social needs that are not elements of medical necessity. Adding to the challenge is the current budgetary crisis for publicly supported programs and services; as fimding diminishes for these resources, the pool of availability shrinks. Occasionally some staff members resist the "control" of the managed care environment, feeling that it impedes their ability to provide appropriate care as it has been traditionally defined. However, clinical pathways and the collection of data that measure both outcomes and cost show strong support for the effectiveness of a managed care approach that emphasizes more timely delivery of health care services. In fact, these two tools provide good guidelines for care teams in moving all patients to achievable goals, regardless of the payment source.
The Outcomes AccountabilityChallenge Often it is the case manager who is viewed as the point person for outcomes accountability. In reality, however, the actions of all staff influence each patient outcome, contributing to this accountability. For this reason, it is absolutely essential for each member of the care team to be knowledgeable about the expectations of the patient, physician, and payer as well as any regulatory or reimbursement requirements that could affect treatment planning.
62TOM
9
OCT/NOV/DEC 1995
It is important for providers to have systems in place that obtain this information so it can be incorporated into treatment planning on an ongoing basis. In today's managed care environment, with its emphasis on services that are medically necessary and timely, it is inappropriate, and often counterproductive, for case management responsibility to rest with a single individual. All care team members must take collective and collaborative responsibility for case management as the framework within which treatment will take place.
patient and the external case manager in discharge planning. Assessing barriers and identifying resources up front can assist the care team in implementing appropriate and timely treatment approaches. Early involvement of the patient and family assists in transition of responsibility to them, encouraging a sense of ownership about recovery goals. It also helps identify barriers that might otherwise remain undetected until discharge, aiding the care team to plan and secure appropriate resources to meet discharge needs.
Along with the clinical status, preadmission systems need to examine the social, safety, and architectural barriers to discharge. It is important to involve both the
An integrated approach to managing patient care is especially helpful when the patient's needs vary from the clinical pathway. It is important for the care team
to be able to communicate unusual patient needs to the external case manager, clearly, tangibly, and in terms of medical necessity. A common situation, for example, arises when the care team perceives a need to increase the patient's level of independence. Traditional treatment protocols would manage this need by increasing the length of stay. However, the patient's barriers to a higher level of independence often are safety, social, or architectural, not medical necessity. In a situation where case management is integrated throughout the care team, team members are alert to these distinctions and have systems in place to identify available resources - - such as more intense therapy during the patient's stay or outpatient/home services - - early on in t h e discharge planning process to support the expected discharge. Patient, family, physician, and payer are all part of this process and participate fully in selection of options that best meet the patient's needs.
The Future Is Managed Care m And Case Management Managed care programs comprise an ever-increasing segment of payment sources nationwide, approaching 50% or more in some parts of the country. Subacute care programs that succeed in this environment are those that plan, implement, and assess patient care on a continuous basis. Integrating comprehensive case management techniques can help subacute programs avoid common reimbursement pitfalls and develop strong, outcomes-oriented programs that meet the needs of both patients and payers.
Mary Flannery, RN, CRRN, CCM, is regional director of managed care for The Hillhaven Corporation's northeast region. She is responsible for subacute program development, managed care contracting, and worka'ng with admh~istrators and case managers to coordinate case management services.
Reprintorders:Mosby--YearBook,Inc., 11830 WestlineIndustrialDrive,St. Louis,MO63146-3318; phone(314)453-4350;reprintno. 88/'1/lig877
Utilization/Quality ManagementManager Managed Care e're Children's Health Net (CHN), the managed care organization of The Children's Hospital of Philadelphia, Children's Physician Practice Plans and Affiliated Physicians. Currently, we're seeking a creative, entrepreneurial RN to supervise our Utilization/Quality Management Department with the goal of setting the national standard for cost effective, high quality pediatric managed care. You will develop and manage the PHO medical management function, clinical guidelines and credentialing; implement UM/QM programs; oversee case management, disease management and referral authorization; and ensure compliance with
M
NCQA and HEDIS standards. Qualified candidates must have a current RN license, Bachelor's degree and at least 5 years of health plan (preferably HMO) UR/CM/QA experience, including management and pediatric experience. Make a positive investment in the future by joining us. You will enjoy a highly competitive salary and comprehensive benefits package. For immediate consideration, please forward resume and salary requirements to: Ruth Frey, Coordinator of Nurse Recruitment, The Children's Hospital of Philadelphia, 34th Street & Civic Center Boulevard, Philadelphia, PA 19104-4399; Fax 215-590-2990. EOE/AA M/F/DN.
CHILDREN 'S HEALTH NET The Managed Care Organization of The Children's Hospital of Philadelphia, the Children's Physician Practice Plans and Affiliated Physicians
OCT/NOV/DEC 1995 9 TCM G3
s the health care environment continues to evolve, more skilled-nursing facilities are developing subacute care programs to provide services for the increasing numbers of patients for w h o m acute hospitalization is no longer appropriate. Administrators generally understand that case management plays an important role in directing positive outcomes as well as controlling costs. This results in their support for systems and procedures that integrate the philosophy of managing care and financial resources within the entire care team. They have
learned that isolating case management responsibilities within a single individual (the case manager) can lead to inappropriate planning and resource utilization, resulting in a treatment team that becomes frustrated with what appear to be conflicting forces - - internal and external - - directing patient care.
position in providing intense, yet costeffective, short-term medical and rehabilitation services has opened the door to new reimbursement sources. More private insurers than ever before now cover subacute services, requiring close coordination between facility care teams and external case managers.
Significant differences in reimbursement systems finCher increase the importance of integrating case management into a subacute care unit's care planning and treatment processes. Subacute care's
The two major reimbursement sources for subacute care are Medicare and managed care insurers. Each has a distinct approach to treatment and reimbursement.
DichotomyOf Systems
OCT/NOV/DEC 1995 9 TOM 61
Currently responsible for the larger percentage of subacute care's reimbursement, Medicare operates according to stringent regulations that govern both the provision of care and reimbursement for qualifying services. It is within this system that most clinicians have become familiar and comfortable in basing treatment protocols. Managed care insurers, on the other hand, typically focus on medical necessity, with an emphasis on moving patients efficiently and cost-effectively to the next level of care. This challenges providers to identify and procure resources to address safety, architectural, and social needs that are not elements of medical necessity. Adding to the challenge is the current budgetary crisis for publicly supported programs and services; as fimding diminishes for these resources, the pool of availability shrinks. Occasionally some staff members resist the "control" of the managed care environment, feeling that it impedes their ability to provide appropriate care as it has been traditionally defined. However, clinical pathways and the collection of data that measure both outcomes and cost show strong support for the effectiveness of a managed care approach that emphasizes more timely delivery of health care services. In fact, these two tools provide good guidelines for care teams in moving all patients to achievable goals, regardless of the payment source.
The Outcomes AccountabilityChallenge Often it is the case manager who is viewed as the point person for outcomes accountability. In reality, however, the actions of all staff influence each patient outcome, contributing to this accountability. For this reason, it is absolutely essential for each member of the care team to be knowledgeable about the expectations of the patient, physician, and payer as well as any regulatory or reimbursement requirements that could affect treatment planning.
62TOM
9
OCT/NOV/DEC 1995
It is important for providers to have systems in place that obtain this information so it can be incorporated into treatment planning on an ongoing basis. In today's managed care environment, with its emphasis on services that are medically necessary and timely, it is inappropriate, and often counterproductive, for case management responsibility to rest with a single individual. All care team members must take collective and collaborative responsibility for case management as the framework within which treatment will take place.
patient and the external case manager in discharge planning. Assessing barriers and identifying resources up front can assist the care team in implementing appropriate and timely treatment approaches. Early involvement of the patient and family assists in transition of responsibility to them, encouraging a sense of ownership about recovery goals. It also helps identify barriers that might otherwise remain undetected until discharge, aiding the care team to plan and secure appropriate resources to meet discharge needs.
Along with the clinical status, preadmission systems need to examine the social, safety, and architectural barriers to discharge. It is important to involve both the
An integrated approach to managing patient care is especially helpful when the patient's needs vary from the clinical pathway. It is important for the care team
to be able to communicate unusual patient needs to the external case manager, clearly, tangibly, and in terms of medical necessity. A common situation, for example, arises when the care team perceives a need to increase the patient's level of independence. Traditional treatment protocols would manage this need by increasing the length of stay. However, the patient's barriers to a higher level of independence often are safety, social, or architectural, not medical necessity. In a situation where case management is integrated throughout the care team, team members are alert to these distinctions and have systems in place to identify available resources - - such as more intense therapy during the patient's stay or outpatient/home services - - early on in t h e discharge planning process to support the expected discharge. Patient, family, physician, and payer are all part of this process and participate fully in selection of options that best meet the patient's needs.
The Future Is Managed Care m And Case Management Managed care programs comprise an ever-increasing segment of payment sources nationwide, approaching 50% or more in some parts of the country. Subacute care programs that succeed in this environment are those that plan, implement, and assess patient care on a continuous basis. Integrating comprehensive case management techniques can help subacute programs avoid common reimbursement pitfalls and develop strong, outcomes-oriented programs that meet the needs of both patients and payers.
Mary Flannery, RN, CRRN, CCM, is regional director of managed care for The Hillhaven Corporation's northeast region. She is responsible for subacute program development, managed care contracting, and worka'ng with admh~istrators and case managers to coordinate case management services.
Reprintorders:Mosby--YearBook,Inc., 11830 WestlineIndustrialDrive,St. Louis,MO63146-3318; phone(314)453-4350;reprintno. 88/'1/lig877
Utilization/Quality ManagementManager Managed Care e're Children's Health Net (CHN), the managed care organization of The Children's Hospital of Philadelphia, Children's Physician Practice Plans and Affiliated Physicians. Currently, we're seeking a creative, entrepreneurial RN to supervise our Utilization/Quality Management Department with the goal of setting the national standard for cost effective, high quality pediatric managed care. You will develop and manage the PHO medical management function, clinical guidelines and credentialing; implement UM/QM programs; oversee case management, disease management and referral authorization; and ensure compliance with
M
NCQA and HEDIS standards. Qualified candidates must have a current RN license, Bachelor's degree and at least 5 years of health plan (preferably HMO) UR/CM/QA experience, including management and pediatric experience. Make a positive investment in the future by joining us. You will enjoy a highly competitive salary and comprehensive benefits package. For immediate consideration, please forward resume and salary requirements to: Ruth Frey, Coordinator of Nurse Recruitment, The Children's Hospital of Philadelphia, 34th Street & Civic Center Boulevard, Philadelphia, PA 19104-4399; Fax 215-590-2990. EOE/AA M/F/DN.
CHILDREN 'S HEALTH NET The Managed Care Organization of The Children's Hospital of Philadelphia, the Children's Physician Practice Plans and Affiliated Physicians
OCT/NOV/DEC 1995 9 TCM G3