Program Purpose • To provide didactic training necessary for the Case Manager to understand the history and importance of a case management department to the financial integrity of the organization.
Program Objectives Upon completion of this section participants will be able to: • Discuss the historical perspective and future state of case management. • Identify the roles and responsibilities of the team members working in case management.
Program Objectives (Cont’d) • Understand legal and ethical issues encountered in case management. • Discuss standards of care for the profession of case management.
What is Case Management? The American Case Management Association (ACMA) 2007 defines case management as: “…a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, care-givers, and the community.” http://www.acmaweb.org/
What is Case Management? ACMA, 2007 Definition (Cont’d): “The case management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of case management include achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient’s right to self-determination.” http://www.acmaweb.org/
Case Management Settings • Hospitals • Insurance companies – auto, disability • Private corporations • Managed care organizations • Home health & mental health agencies • Independent case management companies
Historical Perspective • 1900s - Nurses and Social Workers coordinated public health services. • After WWII, coordinated services for soldiers with complex injuries. • More formalized in the 1970’s with creation of Medicare and Medicaid – services for elderly, low income, and mentally ill.
Historical Perspective As health care costs climbed and cost containment became essential, case management emerged as a means of meeting the patient’s needs and using community resources effectively.
The Future of Case Management • Increased attention on strategies to measure and improve health care across the continuum. • Public reporting demanded by payers, accreditation organizations, state and federal agencies and the consumer.
Evidenced Based Measures • Medicare Prescription Drug, Improvement and Modernization Act of 2003 – hospital voluntary reporting with financial incentive. • Acute MI, CHF, Pneumonia • 10 quality “Core Measures”
American Case Management Association • The American Case Management Association (ACMA) is the first and only non-profit membership organization for Hospital/Health System Case Management professionals. • ACMA was developed for and by Hospital/Health System Case Management professionals ensuring that member needs are foremost in their mission and endeavors.
American Case Management Association Mission “To be THE Association that offers solutions to support the evolving collaborative practice of Hospital/Health System Case Management.”
American Case Management Association Goals • Provide innovative professional development services: • Mentoring • Educational Forums • Resource Information • Create new opportunities for networking. • Influence the policies, laws and other issues related to the practice of Case Management.
ACMA Scope of Services (2007) Advocacy & Education • Patient/Family Self Care Management • Patient/Family Health Management Education • Bioethics Referrals & Management • Physician, Staff, & Community Education
ACMA Scope of Services (2007)(Cont’d) Advocacy & Education • Case Management Education & Training • Risk Management Identification & Referral • Legal Assistance/Coordination • Customer Service/Guest Relations Management
ACMA Scope of Services (2007) Clinical Care Coordination/Facilitation • Plan of Care & Outcomes Management • Patient Care Integration • Resource Management • Patient/Family Care Conferences • Interdisciplinary Care Communication/Coordination • Continuity of Care Planning Management
ACMA Scope of Services (2007) Continuity/Transition Management • Capacity/Access Management & Throughput • Discharge Planning • NH/SNF/Rehab/LTAC/Assisted Living Placement • Transportation & Travel Arrangements • DME • Home Health/Home Infusion • Mental Health Service Coordination
ACMA Scope of Services (2007) Continuity/Transition Management (Cont’d) • Dialysis Coordination & Arrangements • Pharmaceutical Authorization/Management • Community Resource Coordination • Advance Directives • Palliative/End-of-Life Care • Hospice
ACMA Scope of Services (2007) Financial Management • Health Care Resource Management/Clinical Cost Efficiency • Financial Assistance/Referrals • Appeals Management • Entitlement Program Coordination • Patient Benefits Coordination: Medicare/Medicaid/SSI
ACMA Scope of Services (2007) Performance & Outcomes Management • Federal/State/Local Regulatory Agency Compliance • Joint Commission Standards Compliance • Clinical Documentation Management • Core Measures Utilization/Compliance • Patient Safety Compliance
ACMA Scope of Services (2007) Performance & Outcomes Management (cont’d) • Clinical Guidelines/Pathways/Evidenced Based Practice • Quality Improvement Practice Standards • Organizational Financial Performance/Management • Length of Stay • Cost per Case • Denial Management
ACMA Scope of Services (2007) Psychosocial Management • Crisis Intervention • Psychosocial Assessment/Functioning • Counseling Support & Referral • Abuse/Neglect Identification & Referral • Substance Abuse: ETOH/Drug • Adult/Child/Domestic/Elder
ACMA Scope of Services (2007) Psychosocial Management (Cont’d) • Emotional Stability/Coping/Grief/Bereavement Support (Individual & Group) • Adoption • Health/Wellness Promotion
ACMA Scope of Services (2007) Research & Practice Development • Clinical Practice Improvements • Evidenced Based Clinical Practice • Case Management Best Practice Standards Development • Case Management Competency Development
ACMA Scope of Services (2007) Utilization Management • Avoidable Delay Identification, Intervention, and Tracking • Utilization Review • Medical Necessity Review • Severity of Illness • Intensity of Service • Pre-Admission Planning
ACMA Scope of Services (2007) Utilization Management (Cont’d): • Third Party Payer Communication • Level of Care Appropriateness Coordination • Admission Status Determination • Clinical Denial Prevention
Case Management as a Profession National Associations • The American Case Management Association, established in 1999 http://www.acmaweb.org/ • 19 Chapters in the U.S. • Certification- Accredited Case Manager • National Association of Social Work-NASW http://www.socialworkers.org/
Case Management as a Profession (Cont’d) National Associations • Case Management Society of America-CMSA • Society for Social Work Leadership in Healthcare- SSWLHC • http://www.cmsa.org/ • http://www.sswlhc.org/
Standards of Practice Joint Commission Accreditation of Hospital Organizations (JCAHO) • Provision of Care, Treatment, and Services Standards encompass many of the case management functions.
Standards of Practice (Cont’d) Joint Commission Accreditation of Hospital Organizations (JCAHO) • Composed of four core processes: • Assessing patient needs. • Planning care, treatment, and services. • Providing the care, treatment, and services the patient needs. • Coordinating care, treatment, and services.
Provision of Care Abuse and Neglect - PC.3.10 • Patients who may be a victim of abuse and neglect are assessed. • Refer to hospital specific abuse and neglect policy and procedure. • Education is provided yearly to team members. • All team members have the responsibility to report abuse. Joint Commission Accreditation of Hospital Organizations (2007) Standards of Practice Manual.
Provision of Care Providing Care, Treatment, and Services • PC.5.60 – “the hospital coordinates the care, treatment, and services provided to a patient as part of the plan of care, treatment, and services and consistent with the hospital’s scope of care, treatment, and services.” Joint Commission Accreditation of Hospital Organizations (2007) Standards of Practice Manual.
Provision of Care Discharge or Transfer • PC.15.10 – “a process addresses the needs for continuing care, treatment, and services after discharge or transfer.” Joint Commission Accreditation of Hospital Organizations (2007) Standards of Practice Manual.
Provision of Care (Cont’d) Discharge or Transfer • PC.15.20 – “the transfer or discharge of a patient to another level of care, treatment, and services, different professionals, or different settings is based on the patients assessed needs and the hospitals capabilities.” Joint Commission Accreditation of Hospital Organizations (2007) Standards of Practice Manual.
Provision of Care (Cont’d) Discharge or Transfer • PC.15.30 – “when patients are transferred or discharged, appropriate information related to the care, treatment, and services provided is exchanged with other service providers.” Joint Commission Accreditation of Hospital Organizations (2007) Standards of Practice Manual.
Centers for Medicare and Medicaid (CMS): Conditions of Participation Sec. 482.30 Condition of Participation: Utilization Review: • The hospital must have a Utilization Review Plan that provides for a review of services furnished by the institution and by the members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs.
Centers for Medicare and Medicaid (CMS): Conditions of Participation (Cont’d) Sec. 482.30 Condition of Participation: Utilization Review: • A Utilization and Quality Control Quality Improvement Organization (QIO) has assumed binding review of the hospital. (Insert your QIO)
Centers for Medicare and Medicaid (CMS): Conditions of Participation (Cont’d) Sec. 482.30 Condition of participation: Utilization Review (Cont’d) • The hospital must have a utilization review committee. • Discussion of medical necessity denials, avoidable days, quality of care issues. • Update the UR plan per your hospital policy.
Centers for Medicare and Medicaid (CMS): Conditions of Participation (Cont’d) Sec. 482.30 Condition of participation: Utilization Review (Cont’d) • Contact your manager to view a copy of your hospital’s UR plan.
Centers for Medicare and Medicaid (CMS): Conditions of Participation (Cont’d) Sec. 482.43 Condition of Participation: Discharge Planning • The hospital must have in effect a discharge planning process that applies to all patients.
Centers for Medicare and Medicaid (CMS): Conditions of Participation (Cont’d) Sec. 482.43 Condition of Participation: Discharge Planning • The hospital’s policies and procedures must be specified in writing. • Each facility has its own discharge planning policy and procedure.
Components of Case Management • Utilization Review • Discharge Planning • Identifying and preventing delays • Outcomes measurement & management • Denials • Clinical Documentation/DRG Assurance
Case Manager Defined The Commission for Case Manager Certification defines a Case Manager as: “A healthcare professional who is responsible for coordinating the care delivered to a group of patients, based on diagnosis or need. Other responsibilities include patient/family education, advocacy, delays management, outcomes monitoring and management. Case managers work with people to get the healthcare and other community services they need, when they need them, and for the best value.” A Case Manager could be a registered nurse or social worker, depending on the hospital standard. http://www.ccmcertification.org/
Case Manager Roles and Responsibilities • Job Description as per facility. • In this internship program, you will learn the major components or functions of case management. • How these components or roles are implemented may vary by hospital.
Case Manager Job Description (Insert Job Description for Case Manager)
Social Worker Job Description (Insert Job Description for Social Worker)
Case Management Models • Payer Based • Physician Based • Geographic Based
Risk Management • What is Risk Management? The process of measuring or assessing risk and developing strategies to manage the risk. • Risk Management Reporting per facility policy • Risk Management Training per facility policy
Medicare Fraud • Intentional abuse of the Medicare program • Office of the Inspector General maintains confidential hotline for reporting of Medicare fraud. • 1-800-HHS-TIPS (1-800-447-8477) • Or e-mail to HHSTips@oig.hhs.gov • Call your manager before reporting concerns.