The Leader's Guide to Hospital Case Management

by Stefani Daniels, Marianne McHale Ramey

Overview

This text addresses the role of the hospital care manager from a business perspective rather than a nursing perspective. It speaks to the relationship the case manager has with the executive team, managed care contracting office, decision support specialists, as well as medical staff and clinical providers and reveals the value of engaging all of them as allies in pursuit of global objectives on behalf of every stakeholder.

Product Details

ISBN-13:	9780763733544
Publisher:	Jones & Bartlett Learning
Publication date:	05/24/2004
Series:	Jones and Bartlett Series in Case Management
Edition description:	1E
Pages:	329
Product dimensions:	6.02(w) x 9.01(h) x 0.76(d)

About the Author

Phoenix Medical Management, Inc.


Phoenix Medical Management, Inc.

Table of Contents

	Foreword	xi
	Preface	xiii
	Acknowledgements	xv
	Contributors	xvii
	About This Book	xix
Part 1	The Healthcare Environment
1	Background and Business	3
	Introduction	3
	Shift Happens: Trends and Issues	4
	Healthcare Economics and the Hospital Case Manager	4
	Factors Driving Costs	6
	Impact on Hospital Finances	11
	Managed Care Today	12
	Evolution of Hospital Reimbursement	15
	Reimbursement Methodologies	17
	Case Rates	17
	Discount from Charges	17
	Per Diem	18
	Capitation	19
	Physician Reimbursement	19
	Capitation	19
	Resource-Based Relative Value System	20
	Customary, Prevailing, and Reasonable Charges	21
	The Balanced Budget Act of 1997	21
	Ambulatory Payment Classifications	22
	Rehabilitation Reimbursement	22
	Point-of-Care Information on Reimbursement	23
	References	28
	Contributor's Commentary	29
2	Compliance and Regulatory Issues	32
	Introduction	32
	Joint Commission on the Accreditation of Healthcare Organizations	33
	Standards Relevant to Case Management	35
	Interdisciplinary Coordination	37
	Case Management Grand Rounds	37
	Discharge Standards	39
	Screening Options	40
	External Recommendations	41
	Fraud and Abuse	42
	Implications for Hospital Case Management	43
	National Committee on Quality Assurance	44
	Implications for Hospital Case Management	44
	Payer Contracts	45
	The Leapfrog Group	46
	The Health Insurance Portability and Accountability Act of 1996	47
	Implications for Hospital Case Management	48
	References	50
	Contributor's Commentary	50
3	Readiness for Case Management	52
	Introduction	52
	What's so Special about the Hospital Venue?	53
	Program Designation: The Accidental Clinician	54
	Congruency	54
	Leverage	55
	Environmental Assumptions	56
	The Customer Connection	57
	The Physician Customer	58
	Creating the Physician-Case Manager Partnership	60
	Some Practical Pointers	62
	Forces for Change and When to Change	64
	SWOT for Improvement	64
	The Challenge of Change	66
	Change and Transition Models	68
	Finding Your Allies	69
	Aligning Disparate Perceptions	73
	The Visioning Process	74
	Establish Goals	76
	Why Program Intent and Goals Are Important	76
	References	77
	Contributor's Commentary	78
Part 2	Practice Framework
4	Moving in the Right Direction	83
	Introduction	83
	Organizational Culture	84
	Linking Vision and Framework	85
	The "Sacred Whats"	89
	Case Management Definitions	92
	Strategic Direction	94
	Hospital Case Management Models	94
	A Schematic Model	97
	Organizational Alignment	98
	Vertical Alignment	99
	Lateral Relationships	100
	References	100
	Contributor's Commentary	101
5	Map for Action	104
	Introduction	104
	Role and Performance Expectations	105
	The Savvy Case Manager	105
	Background Preparation	107
	The Primary Roles of the Hospital Case Manager	108
	Job Descriptions	109
	Competency-Based Performance Appraisal	115
	Integrating Job Descriptions and Competencies	116
	Accountability and Responsibility	116
	Salary Determination	121
	Case Manager Certification	122
	Training and Continuing Education	124
	Curriculum Modules	125
	Reinforcement, Refreshers, and Reminders	125
	Assigning, Staffing, and Scheduling	130
	Case Manager Assignment	130
	Staff Allocation	133
	Staffing Patterns and Scheduling	134
	Support Staff	136
	The Case Manager and the Social Worker	137
	Case Finding	139
	Documenting Case Management Activities	143
	References	144
	Contributor's Commentary	145
6	Building a Case Management Team	147
	Introduction	147
	Team Characteristics	148
	Building a Cohesive Case Management Team	149
	Team Building Strategies	150
	Critical Thinking Skills	152
	A Commitment to Collaboration	156
	The Essential Teammate: The Social Worker	156
	The Medical Advisor	159
	Interdisciplinary Teams	161
	Daily Interdisciplinary Meetings	161
	Coordination of Care Committees	162
	Collaborative Physician Partnerships	163
	Leading the Team	165
	Managing the Program	166
	Public Relations Specialist	167
	Reaching Decision Makers	169
	Managing the Case Managers	170
	The Team and the Future	171
	References	171
	Contributor's Commentary	172
Part 3	Operations and Management
7	Clinical Management Initiatives	177
	Introduction	177
	Clinical Protocols and Evidence-Based Medicine	177
	Variations on the Theme of Clinical Pathways	178
	Evidence-Based Medicine	179
	Protocols and Case Management	180
	On-Line Protocols	181
	Designing Protocols	182
	Practice Variations and the Dartmouth Atlas	183
	More is Not Better	185
	Real-Time Collaboration	185
	Performance Profiling	187
	"Show Me the Facts and Spare Me the Opinions"	188
	The Anticipated Challenge	192
	Crossing the Continuum	195
	Access to Care	195
	The Emergency Department Case Manager	196
	The Face Sheet Factor	197
	The Acute Care Episode	198
	Discharge Planning	205
	Interdisciplinary Involvement	207
	Extending Beyond the Boundaries	208
	References	210
	Contributor's Commentary	213
	Contributor's Commentary	214
8	Resource Management Initiatives	217
	Introduction	217
	Utilization Review	218
	Contractual UR	219
	PRO Scope of Work	220
	State Licensing Requirements	220
	The Typical UR Process	222
	Transition to Resource Management	228
	"The Hospital is No Place to Be if You Are Seriously Ill"	228
	Resource Management Initiatives	230
	Appropriateness of the Service	230
	Efficiency of the Service Delivery	232
	Doctors, Documentation, DRGS, and Dollars	242
	Point-of-Care Documentation Improvement	244
	Documentation Support Options	244
	Case Management Documentation Support	245
	Using Documentation Tools	247
	Reimbursement Mechanisms	250
	References	253
	Contributor's Commentary	254
9	Putting the Pieces Together	257
	Introduction	257
	Developing the Strategic Plan	258
	Write It Down	259
	The Operational Plan	260
	Timelines	261
	Case Management Software Applications	266
	Decision Support Technology	271
	Professional Responsibilities	273
	Accountability	273
	Responsibility	276
	Ethical Behavior	277
	The Legal Landscape	277
	Client Consent	278
	Confidentiality and Privacy	278
	Patient Rights	279
	Denial of Service	281
	Legal Exposure	281
	Respondeat Superior Is Not Enough	282
	References	283
	Contributor's Commentary	284
10	Case Management Program Outcomes	288
	Introduction	288
	What Are Outcomes?	289
	Outcomes and Productivity	291
	What to Measure?	291
	Clinical Outcomes	293
	Cost Outcomes	294
	Revenue Outcomes	294
	Value Outcomes	295
	A Framework of Outcome Measures	296
	Framework Models	297
	From Framework to Format	300
	Managing for Value	301
	Turning Data Into Information	303
	Death by Data	306
	The Slavish Focus on Length of Stay	307
	Return on Investment	309
	National Outcome Initiatives	311
	References	312
	Contributor's Commentary	313
	Index	317