- Email: [email protected]
Case management and quality: Have we reached a tipping point?
Case Management and Quality: Have We Reached a Tipping Point?
Sherrie Dulworth, RN, CPHRM
I
n The Tipping Point,1 Malcolm Gladwell describes a phenomenon in which a niche market or fad undergoes transformation into mainstream acceptability, resulting in widespread social change. He concludes that a “tipping point” occurs when a series of small events results in a critical mass of acceptance that produces sudden major changes.
In recent years, health-care quality measures have gained support in both the public and private sectors. Measures developed by nationally recognized organizations are being used by payers and providers for various purposes: pay-for-performance, network selection, tiering and reimbursement, and identifying important quality-improvement opportunities. For decades, case managers, whose roles range from management of catastrophic injuries to chronic diseases, have worked with those same
payers and providers to coordinate patient care in various care settings, such as the hospital, rehabilitation centers, physician offices, and home care. Although accountability for improving quantifiable quality processes or outcomes has not been a widespread expectation or requirement for this role, in recent years the importance of case managers’ contribution to improving quality of care has expanded. What are the current expectations and opportunities for case managers to contribute to
the quality momentum, and could they be approaching a tipping point? The CMSA Standards of Practice for Case Management2 lists quality of care among its performance indicators: “Quality-based outcomes include such indicators as improved functional status, improved clinical status, enhanced quality of life, client satisfaction, adherence to the treatment plan, improved client safety, cost savings, and client autonomy.” Two of the measurement September/October 2006
TCM 59
guidelines for the quality-of-care indicator are: • Use evaluative and outcomes data to improve case management services • Promote health-care outcomes in concert with evidence-based guidelines whenever possible The URAC’s Case Management Accreditation Standards3 states, “…the organization conducts case reviews to promote achievement of case management goals and uses the information for quality management.” In 2005, the National Committee for Quality Assurance (NCQA) introduced new standards for care management and health improvement.4 Along with a focus on three primary areas—wellness and prevention, managing members with chronic conditions, and complex case management—these standards also evaluate organizations’ overall case management processes, including the methods used for program-effectiveness measurement. The now voluntary standards will become mandatory in 2007 as part of NCQA’s accreditation review process. Evidence-based guidelines are produced by a number of organizations, both public and private, and are one tool that can help the case manager improve the quality of care by identifying key process steps for best practice treatment. This article addresses specific quality indicators within the Milliman Care Guidelines5 and their use by individuals and organizations; however, because other guidelines may have similar functionality, this article remains applicable to a wider audience. Benchmarking Reality The Centers for Medicare & Medicaid Services (CMS) Hospital Quality Initiative6 focuses on improved hospital quality in four main areas: acute myocardial infarction, heart failure, pneumonia, and surgical infection prevention. The results, as revealed by the Health and Human Services Hospital Compare report,7 show that, despite the widespread emphasis on these associated measures, significant room for improvement exists in some areas. For example, with the frequently case-managed diagnosis of heart failure, the percentage of patients given disTCM 60
September/October 2006
charge instructions (in all reporting US hospitals through June 2005) was only 50%. The national average for the hospitals that offered heart failure patients smoking cessation advice or counseling was 71%. The NCQA 2005 State of Health Care Quality report8 identifies a similar pattern in the outpatient setting, in which about 69% of patients enrolled in commercial health plans received smoking cessation advice from practitioners. Although the NCQA data certainly have shown a slight upward trend in compliance in recent years, there is no doubt that opportunity for quality improvement exists when over 30% of the patients do not receive the appropriate basic counseling, despite being in the presence of a health-care expert. Milliman Care Guidelines contains information and content links for several nationally recognized quality measures, including the CMS Hospital Quality Initiatives, LeapFrogGroup’s Hospital Rewards Program, and the Health Plan Employer Data and Information Set (HEDIS) Effectiveness of Care measures. For example, a 2006 first-year HEDIS measure9 is the use of spirometry testing in the assessment and diagnosis of chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States. It affects the lives of more than 10 million Americans,10 is a highly debilitating disease, may be a comorbidity for other chronic conditions such as cardiac disease, and is often managed by case managers. The HEDIS measure looks at the “percentage of members 40 years of age and older with a new diagnosis or newly active COPD who received appropriate spirometry testing to confirm the diagnosis.”9 The Agency for Healthcare Quality and Research (AHRQ) summary on the Use of Spirometry for Case Finding, Diagnosis, and Management of Chronic Obstructive Pulmonary Disease (COPD)11 points out, “Spirometry in addition to clinical examination improves COPD diagnostic accuracy compared to clinical examination alone and it is a useful diagnostic tool in individuals with symptoms suggestive of possible COPD. The primary benefit of spirometry is to identify individuals who
might benefit from pharmacologic treatment to improve exacerbations. These include adults with symptomatic, severe, to very severe airflow obstruction.” The screen in Figure 1 shows how the Optimum Treatment Guideline for the COPD Diagnostic Testing section12 flags the content with bold QM, alerting the case manager to the relationship and importance of this particular quality measure. By comparing the patient’s actual treatment plan to the care guideline, the case manager can identify opportunities to improve quality of care by identifying and intervening in the need for spirometry testing with appropriate patients. Expanded Opportunities A report on the CMS Medicare Quality Improvement Organization Program Priorities13 cites that hospitalization after home health care is an area of concern. The document says, “Significant contributors to avoidable hospital admissions include delivery system problems such as suboptimal assessment of a patient’s readiness for hospital discharge, fragmented or incomplete hospital discharge planning, poor communication and insufficient information transfer from hospitalbased to community providers, insufficient monitoring of home health care patients, or some combination.” The report continues, “The strongest evidence exists for improvements in hospital discharge planning and in patient transitions from hospital to home.” The coordination of discharge care, monitoring of home health, and prevention of readmission are basic functions of the case management role, and readmission after home health is a measurable factor that organizations can track. Using the care guidelines, the case manager or organization responsible for care management can assist with this function by focusing on the following components: • Recovery milestones for hospital discharge. Case management organizations can develop oversight programs to ensure that appropriate discharge assessment and documentation are completed. For example, within the Care Guidelines’ Inpatient and Surgical Care, the final day of the pathway lists Recovery Milestones,1 indicating that the patient may be ready for discharge to a lower level of care. An organization could draw on the discharge
Table 1. Discharge Planning for Heart Failure Initiate early comprehensive discharge planning with postdischarge support Coordinate development of treatment goals and plans with multiple caregivers, including but not limited to: • Primary care physician • Cardiologist • Respiratory therapist • Dietitian • Cardiac rehabilitation specialist • Social Services • Home care provider Assess home safety, needs, and capabilities • Safety factors • Ability to manage self-care • Availability of adequate home caregiver • Need for home healthcare visits for skilled nursing care and rehabilitation • Need for respiratory or oxygen therapy • Need for durable medical equipment • Need for intravenous infusion therapy Facilitate decision and transition to home or recovery facility Consider integration of palliative care Ensure follow-up care arranged Ensure timely referral to appropriate community resources and applications for public funding Refer to disease management program, if available, or close follow-up care Manage medication • Review medications regularly taken prior to hospitalization and advise as to continuance • Review newly prescribed medications, including how and when prescriptions will be obtained Educate patient, family, and caregiver • Nature and cause of heart failure, prognosis, and advance directives • Treatment plan and role of family and caregiver • Importance of regular follow-up care • Medication administration, side effects, interactions, and adverse reactions • Maintain adequate nutrition • Diet high in fruit and vegetable consumption • Low-salt, low-fat diet • Mild to moderate fluid restriction • Possible potassium supplements • Alcohol avoidance • Weight reduction for obese patient • Increased nutrition for patient at risk for cachexia • Monitor and record daily weight • Stop smoking • Effectively manage stress • Encourage appropriate activity and exercise level • Recognize signs and symptoms of complications, whom to contact, and how and when to seek medical intervention • Chest pain • Worsening dyspnea • Orthopnea • Paroxysmal nocturnal dyspnea • Sudden weight gain • Decreased exercise tolerance • Increased fatigue • New or worsening edema, cough, or dizziness • Nausea, vomiting, diarrhea, or loss of appetite • Change in mentation • Difficulty sleeping • Increased pillow use • Cough • Pitting edema • Increased shortness of breath at rest • Depressed mood • Markedly diminished interest or pleasure in activities • Discuss • Need for advance directives • Possible palliative care Perform routine discharge planning
recovery milestones to evaluate patient discharge readiness, case management’s timeliness of response to this readiness, and the documentation of the overall organizational performance in this area. • Case management, discharge planning. The discharge planning section gives the case manager detailed discharge planning instructions and patient/caregiver education. Table 1 provides an example of the hospital discharge planning instructions for heart failure. While an experienced case manager with cardiac expertise might occasionally remember some of these instructions, it is improbable that all case managers will universally remember to evaluate each of these areas all of the time. Hence, using the care guidelines as a reference helps ensure that case managers achieve a consistent discharge planning process and decreases the chance of unintentional oversight. • Home safety. Reference tools also can facilitate the case management promotion of quality measures within the home care setting. Among the 2006 Joint Commission Home Care National Patient Safety Goals14 are Goal 9, “Reduce the risk of patient harm resulting from falls,” and Goal 9B, “Implement a fall reduction program and evaluate the effectiveness of the program.” Appendices found in some of the care guidelines publications, such as Appendix H: Home Safety Assessment,15 can be used for individual case reviews and for organizational systematic measurement of the percentage of cases in which a home safety assessment is performed for at-risk populations. One of NCQA’s standards for evaluating the complex case management process16 is the “Initial Assessment of Activities of Daily Living,” and the Care Guidelines Appendix L: Activities of Daily Living and Instrumental Activities of Daily Living Assessment17 is an example of another such tool for improving this quality metric. Great Expectations The use of clinical guidelines as a means to avoid delays and omissions in care is becoming more widely accepted. A survey conducted by URAC revealed that in 2005,18 58% of the utilization and case companies surveyed reported quality measurement activity related to “coordiSeptember/October 2006
TCM 61
nation of care.” The survey further found that of the 252 companies surveyed, 223 expected to perform more dischargeplanning activities in the future. An article from the Healthcare Financial Management Association on “The Case for Quality: Effective Clinical and Financial Case Management”19 points out that “case managers are the link between the art and science of medicine ...” By using evidence-based references and focusing on measurable quality initiatives, the case manager strengthens the science in the equation. Case managers can provide a vital role in the improvement of patient-care quality by optimal use of evidence-based resources. An article in the Topics in Advanced Practice Nursing eJournal promoting the role and perception of nurses as professionals says, “The public needs to know that nurses— regular, ordinary bedside nurses, not just nurse practitioners or advanced practice nurses—are constantly participating in the act of medical diagnosis, prescription, and treatment and thus make a real difference in medical outcomes” (emphasis added). The same could be said of case managers and their contribution to the advancement of quality care. ❑ References 1. Gladwell M. The tipping point. Boston: Little, Brown; 2000. 2. Case Management Society of America. Standards for case management. Little Rock: The Society; 2002: 13. 3. URAC. Case management accreditation standards summary. Available from: www.urac.org/prog_accred_cm_ss.asp?navid= accreditation&pagename=prog_accred_CM. Accessed May 22, 2006. 4. National Committee for Quality Assurance. Quality Plus Program for Managed Care Organizations, Care Management and Health Improvement. Standards. 2005. Available from: http://www.ncqa.org/Programs/ Qualityplus/index.htm. Accessed June 26, 2006. 5. Milliman Care Guidelines. 10th ed. Inpatient and surgical care, case management: heart failure. Available from: http://www.careguide lines.com/pdf/0222_EBM_WEB.pdf. Accessed July 5, 2006. 6. Centers for Medicare and Medicaid. Hospital quality initiative overview. December 2005. Available from: http://www.cms.hhs.gov/HospitalQuality Inits/downloads/HospitalOverview200512 .pdf. Accessed May 22, 2006. 7. US Department of Health and Human Services. Hospital compare. Available from: www.hospitalcompare.hhs.gov. Accessed May 22, 2006.
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8. National Committee for Quality Assurance. The state of healthcare quality 2005. Available from: http://www.ncqa.org/Docs/SOHCQ_2005 .pdf. Accessed June 26, 2006. 9. National Committee for Quality Assurance. HEDIS effectiveness of care measures, 2006. Available from: www.ncqa.org. Accessed June 26, 2006. 10.American Lung Association. COPD fact sheet, July 2005. Available from: http://www. lungusa.org/. Accessed May 22, 2006. 11.Agency for Healthcare Research and Quality. Evidence report/technology assessment: number 121. Use of spirometry for case finding, diagnosis, and management of chronic obstructive pulmonary disease (COPD). Available from: http://www.ahrq.gov/clinic/ epcsums/spirosum.htm. Accessed May 22, 2006. 12.Milliman Care Guidelines. 10th ed. Ambulatory care, optimum treatment guidelines. Available from: http://www.careguidelines.com/ products/10thed.htm. Accessed June 26, 2006. 13.Centers for Medicare and Medicaid. Medicare quality improvement organization program priorities. Available from: http://www. MedQIC.org. Accessed May 22, 2006. 14.Joint Commission on Accreditation of Healthcare Organizations. 2006 home care national patient safety goals. Available from: http://www.jointcommission.org/Accreditation Programs/HomeCare/. Accessed May 30, 2006. 15.Milliman Care Guidelines. 10th ed. Inpatient and surgical care, appendices. Available from: http://www.careguidelines.com/ products/10thed.htm. Accessed June 26, 2006. 16.National Committee for Quality Assurance. Quality Plus Program for Managed Care Organizations, Care Management and Health Improvement. Standards, CHI 3, Complex Case Management. Accessed October 1, 2005. 17.Milliman Care Guidelines. 10th ed. Inpatient and surgical care, appendices. Available from: http://www.careguidelines.com/ products/10thed.htm. Accessed June 26, 2006. 18.Carneal G, Watson A. An overview of trends and challenges impacting the practice of case management. Presentation at CMSA Conference, June 24, 2005, Orlando, Florida. 19.Healthcare Financial Management Association. The case for quality: effective clinical and financial case management. June 2005. Available from: http://www.hfma.org/publications/. Accessed May 26, 2006.
Sherrie Dulworth, RN, CPHRM, is the director of strategic planning and development for Milliman Care Guidelines in Seattle, Washington. Reprint orders: E-mail [email protected] or phone (toll-free) 888-834-7287; reprint no. YMCM 416 doi:10.1016/j.casemgr.2006.06.005
Sherrie Dulworth, RN, CPHRM
I
n The Tipping Point,1 Malcolm Gladwell describes a phenomenon in which a niche market or fad undergoes transformation into mainstream acceptability, resulting in widespread social change. He concludes that a “tipping point” occurs when a series of small events results in a critical mass of acceptance that produces sudden major changes.
In recent years, health-care quality measures have gained support in both the public and private sectors. Measures developed by nationally recognized organizations are being used by payers and providers for various purposes: pay-for-performance, network selection, tiering and reimbursement, and identifying important quality-improvement opportunities. For decades, case managers, whose roles range from management of catastrophic injuries to chronic diseases, have worked with those same
payers and providers to coordinate patient care in various care settings, such as the hospital, rehabilitation centers, physician offices, and home care. Although accountability for improving quantifiable quality processes or outcomes has not been a widespread expectation or requirement for this role, in recent years the importance of case managers’ contribution to improving quality of care has expanded. What are the current expectations and opportunities for case managers to contribute to
the quality momentum, and could they be approaching a tipping point? The CMSA Standards of Practice for Case Management2 lists quality of care among its performance indicators: “Quality-based outcomes include such indicators as improved functional status, improved clinical status, enhanced quality of life, client satisfaction, adherence to the treatment plan, improved client safety, cost savings, and client autonomy.” Two of the measurement September/October 2006
TCM 59
guidelines for the quality-of-care indicator are: • Use evaluative and outcomes data to improve case management services • Promote health-care outcomes in concert with evidence-based guidelines whenever possible The URAC’s Case Management Accreditation Standards3 states, “…the organization conducts case reviews to promote achievement of case management goals and uses the information for quality management.” In 2005, the National Committee for Quality Assurance (NCQA) introduced new standards for care management and health improvement.4 Along with a focus on three primary areas—wellness and prevention, managing members with chronic conditions, and complex case management—these standards also evaluate organizations’ overall case management processes, including the methods used for program-effectiveness measurement. The now voluntary standards will become mandatory in 2007 as part of NCQA’s accreditation review process. Evidence-based guidelines are produced by a number of organizations, both public and private, and are one tool that can help the case manager improve the quality of care by identifying key process steps for best practice treatment. This article addresses specific quality indicators within the Milliman Care Guidelines5 and their use by individuals and organizations; however, because other guidelines may have similar functionality, this article remains applicable to a wider audience. Benchmarking Reality The Centers for Medicare & Medicaid Services (CMS) Hospital Quality Initiative6 focuses on improved hospital quality in four main areas: acute myocardial infarction, heart failure, pneumonia, and surgical infection prevention. The results, as revealed by the Health and Human Services Hospital Compare report,7 show that, despite the widespread emphasis on these associated measures, significant room for improvement exists in some areas. For example, with the frequently case-managed diagnosis of heart failure, the percentage of patients given disTCM 60
September/October 2006
charge instructions (in all reporting US hospitals through June 2005) was only 50%. The national average for the hospitals that offered heart failure patients smoking cessation advice or counseling was 71%. The NCQA 2005 State of Health Care Quality report8 identifies a similar pattern in the outpatient setting, in which about 69% of patients enrolled in commercial health plans received smoking cessation advice from practitioners. Although the NCQA data certainly have shown a slight upward trend in compliance in recent years, there is no doubt that opportunity for quality improvement exists when over 30% of the patients do not receive the appropriate basic counseling, despite being in the presence of a health-care expert. Milliman Care Guidelines contains information and content links for several nationally recognized quality measures, including the CMS Hospital Quality Initiatives, LeapFrogGroup’s Hospital Rewards Program, and the Health Plan Employer Data and Information Set (HEDIS) Effectiveness of Care measures. For example, a 2006 first-year HEDIS measure9 is the use of spirometry testing in the assessment and diagnosis of chronic obstructive pulmonary disease (COPD), the fourth leading cause of death in the United States. It affects the lives of more than 10 million Americans,10 is a highly debilitating disease, may be a comorbidity for other chronic conditions such as cardiac disease, and is often managed by case managers. The HEDIS measure looks at the “percentage of members 40 years of age and older with a new diagnosis or newly active COPD who received appropriate spirometry testing to confirm the diagnosis.”9 The Agency for Healthcare Quality and Research (AHRQ) summary on the Use of Spirometry for Case Finding, Diagnosis, and Management of Chronic Obstructive Pulmonary Disease (COPD)11 points out, “Spirometry in addition to clinical examination improves COPD diagnostic accuracy compared to clinical examination alone and it is a useful diagnostic tool in individuals with symptoms suggestive of possible COPD. The primary benefit of spirometry is to identify individuals who
might benefit from pharmacologic treatment to improve exacerbations. These include adults with symptomatic, severe, to very severe airflow obstruction.” The screen in Figure 1 shows how the Optimum Treatment Guideline for the COPD Diagnostic Testing section12 flags the content with bold QM, alerting the case manager to the relationship and importance of this particular quality measure. By comparing the patient’s actual treatment plan to the care guideline, the case manager can identify opportunities to improve quality of care by identifying and intervening in the need for spirometry testing with appropriate patients. Expanded Opportunities A report on the CMS Medicare Quality Improvement Organization Program Priorities13 cites that hospitalization after home health care is an area of concern. The document says, “Significant contributors to avoidable hospital admissions include delivery system problems such as suboptimal assessment of a patient’s readiness for hospital discharge, fragmented or incomplete hospital discharge planning, poor communication and insufficient information transfer from hospitalbased to community providers, insufficient monitoring of home health care patients, or some combination.” The report continues, “The strongest evidence exists for improvements in hospital discharge planning and in patient transitions from hospital to home.” The coordination of discharge care, monitoring of home health, and prevention of readmission are basic functions of the case management role, and readmission after home health is a measurable factor that organizations can track. Using the care guidelines, the case manager or organization responsible for care management can assist with this function by focusing on the following components: • Recovery milestones for hospital discharge. Case management organizations can develop oversight programs to ensure that appropriate discharge assessment and documentation are completed. For example, within the Care Guidelines’ Inpatient and Surgical Care, the final day of the pathway lists Recovery Milestones,1 indicating that the patient may be ready for discharge to a lower level of care. An organization could draw on the discharge
Table 1. Discharge Planning for Heart Failure Initiate early comprehensive discharge planning with postdischarge support Coordinate development of treatment goals and plans with multiple caregivers, including but not limited to: • Primary care physician • Cardiologist • Respiratory therapist • Dietitian • Cardiac rehabilitation specialist • Social Services • Home care provider Assess home safety, needs, and capabilities • Safety factors • Ability to manage self-care • Availability of adequate home caregiver • Need for home healthcare visits for skilled nursing care and rehabilitation • Need for respiratory or oxygen therapy • Need for durable medical equipment • Need for intravenous infusion therapy Facilitate decision and transition to home or recovery facility Consider integration of palliative care Ensure follow-up care arranged Ensure timely referral to appropriate community resources and applications for public funding Refer to disease management program, if available, or close follow-up care Manage medication • Review medications regularly taken prior to hospitalization and advise as to continuance • Review newly prescribed medications, including how and when prescriptions will be obtained Educate patient, family, and caregiver • Nature and cause of heart failure, prognosis, and advance directives • Treatment plan and role of family and caregiver • Importance of regular follow-up care • Medication administration, side effects, interactions, and adverse reactions • Maintain adequate nutrition • Diet high in fruit and vegetable consumption • Low-salt, low-fat diet • Mild to moderate fluid restriction • Possible potassium supplements • Alcohol avoidance • Weight reduction for obese patient • Increased nutrition for patient at risk for cachexia • Monitor and record daily weight • Stop smoking • Effectively manage stress • Encourage appropriate activity and exercise level • Recognize signs and symptoms of complications, whom to contact, and how and when to seek medical intervention • Chest pain • Worsening dyspnea • Orthopnea • Paroxysmal nocturnal dyspnea • Sudden weight gain • Decreased exercise tolerance • Increased fatigue • New or worsening edema, cough, or dizziness • Nausea, vomiting, diarrhea, or loss of appetite • Change in mentation • Difficulty sleeping • Increased pillow use • Cough • Pitting edema • Increased shortness of breath at rest • Depressed mood • Markedly diminished interest or pleasure in activities • Discuss • Need for advance directives • Possible palliative care Perform routine discharge planning
recovery milestones to evaluate patient discharge readiness, case management’s timeliness of response to this readiness, and the documentation of the overall organizational performance in this area. • Case management, discharge planning. The discharge planning section gives the case manager detailed discharge planning instructions and patient/caregiver education. Table 1 provides an example of the hospital discharge planning instructions for heart failure. While an experienced case manager with cardiac expertise might occasionally remember some of these instructions, it is improbable that all case managers will universally remember to evaluate each of these areas all of the time. Hence, using the care guidelines as a reference helps ensure that case managers achieve a consistent discharge planning process and decreases the chance of unintentional oversight. • Home safety. Reference tools also can facilitate the case management promotion of quality measures within the home care setting. Among the 2006 Joint Commission Home Care National Patient Safety Goals14 are Goal 9, “Reduce the risk of patient harm resulting from falls,” and Goal 9B, “Implement a fall reduction program and evaluate the effectiveness of the program.” Appendices found in some of the care guidelines publications, such as Appendix H: Home Safety Assessment,15 can be used for individual case reviews and for organizational systematic measurement of the percentage of cases in which a home safety assessment is performed for at-risk populations. One of NCQA’s standards for evaluating the complex case management process16 is the “Initial Assessment of Activities of Daily Living,” and the Care Guidelines Appendix L: Activities of Daily Living and Instrumental Activities of Daily Living Assessment17 is an example of another such tool for improving this quality metric. Great Expectations The use of clinical guidelines as a means to avoid delays and omissions in care is becoming more widely accepted. A survey conducted by URAC revealed that in 2005,18 58% of the utilization and case companies surveyed reported quality measurement activity related to “coordiSeptember/October 2006
TCM 61
nation of care.” The survey further found that of the 252 companies surveyed, 223 expected to perform more dischargeplanning activities in the future. An article from the Healthcare Financial Management Association on “The Case for Quality: Effective Clinical and Financial Case Management”19 points out that “case managers are the link between the art and science of medicine ...” By using evidence-based references and focusing on measurable quality initiatives, the case manager strengthens the science in the equation. Case managers can provide a vital role in the improvement of patient-care quality by optimal use of evidence-based resources. An article in the Topics in Advanced Practice Nursing eJournal promoting the role and perception of nurses as professionals says, “The public needs to know that nurses— regular, ordinary bedside nurses, not just nurse practitioners or advanced practice nurses—are constantly participating in the act of medical diagnosis, prescription, and treatment and thus make a real difference in medical outcomes” (emphasis added). The same could be said of case managers and their contribution to the advancement of quality care. ❑ References 1. Gladwell M. The tipping point. Boston: Little, Brown; 2000. 2. Case Management Society of America. Standards for case management. Little Rock: The Society; 2002: 13. 3. URAC. Case management accreditation standards summary. Available from: www.urac.org/prog_accred_cm_ss.asp?navid= accreditation&pagename=prog_accred_CM. Accessed May 22, 2006. 4. National Committee for Quality Assurance. Quality Plus Program for Managed Care Organizations, Care Management and Health Improvement. Standards. 2005. Available from: http://www.ncqa.org/Programs/ Qualityplus/index.htm. Accessed June 26, 2006. 5. Milliman Care Guidelines. 10th ed. Inpatient and surgical care, case management: heart failure. Available from: http://www.careguide lines.com/pdf/0222_EBM_WEB.pdf. Accessed July 5, 2006. 6. Centers for Medicare and Medicaid. Hospital quality initiative overview. December 2005. Available from: http://www.cms.hhs.gov/HospitalQuality Inits/downloads/HospitalOverview200512 .pdf. Accessed May 22, 2006. 7. US Department of Health and Human Services. Hospital compare. Available from: www.hospitalcompare.hhs.gov. Accessed May 22, 2006.
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September/October 2006
8. National Committee for Quality Assurance. The state of healthcare quality 2005. Available from: http://www.ncqa.org/Docs/SOHCQ_2005 .pdf. Accessed June 26, 2006. 9. National Committee for Quality Assurance. HEDIS effectiveness of care measures, 2006. Available from: www.ncqa.org. Accessed June 26, 2006. 10.American Lung Association. COPD fact sheet, July 2005. Available from: http://www. lungusa.org/. Accessed May 22, 2006. 11.Agency for Healthcare Research and Quality. Evidence report/technology assessment: number 121. Use of spirometry for case finding, diagnosis, and management of chronic obstructive pulmonary disease (COPD). Available from: http://www.ahrq.gov/clinic/ epcsums/spirosum.htm. Accessed May 22, 2006. 12.Milliman Care Guidelines. 10th ed. Ambulatory care, optimum treatment guidelines. Available from: http://www.careguidelines.com/ products/10thed.htm. Accessed June 26, 2006. 13.Centers for Medicare and Medicaid. Medicare quality improvement organization program priorities. Available from: http://www. MedQIC.org. Accessed May 22, 2006. 14.Joint Commission on Accreditation of Healthcare Organizations. 2006 home care national patient safety goals. Available from: http://www.jointcommission.org/Accreditation Programs/HomeCare/. Accessed May 30, 2006. 15.Milliman Care Guidelines. 10th ed. Inpatient and surgical care, appendices. Available from: http://www.careguidelines.com/ products/10thed.htm. Accessed June 26, 2006. 16.National Committee for Quality Assurance. Quality Plus Program for Managed Care Organizations, Care Management and Health Improvement. Standards, CHI 3, Complex Case Management. Accessed October 1, 2005. 17.Milliman Care Guidelines. 10th ed. Inpatient and surgical care, appendices. Available from: http://www.careguidelines.com/ products/10thed.htm. Accessed June 26, 2006. 18.Carneal G, Watson A. An overview of trends and challenges impacting the practice of case management. Presentation at CMSA Conference, June 24, 2005, Orlando, Florida. 19.Healthcare Financial Management Association. The case for quality: effective clinical and financial case management. June 2005. Available from: http://www.hfma.org/publications/. Accessed May 26, 2006.
Sherrie Dulworth, RN, CPHRM, is the director of strategic planning and development for Milliman Care Guidelines in Seattle, Washington. Reprint orders: E-mail [email protected] or phone (toll-free) 888-834-7287; reprint no. YMCM 416 doi:10.1016/j.casemgr.2006.06.005