CHAPTER ELEVEN

1. CHAPTER ELEVEN CASE MANAGEMENT

2. What is Case Management? • Definition: • A system by which one professional is responsible for assuring that a patient receives a full spectrum of services required • A Case Manager acts as a broker to arrange both hospital and community services • Case management includes: • comprehensive assessment of needs and resources, development of a care plan, referral follow-up, and periodic evaluation of the plan

3. Origins of Case Management • Documented in the early 1900s in settlement houses and charity • Administrators in many public and social programs used it to coordinate individual methods of locating resources, primarily for: • children who had benefit coverage under the Children’s Medical Security program • military servicemen returning from WWII • elderly • mentally ill who were at risk of placement in LTC facilities

4. Origins of Case Management • Continued to be used by social workers and nurses in public welfare, health and mental health programs • 1970s and 1980s federal government funded community-based research and demonstration projects to test LTC coordination approaches and financing • 1980s and 1990s healthcare payors patterned their programs after workers’ compensation management programs, offering similar services to clients with “catastrophic” or highly expensive medical illnesses

5. Origins of Case Management • States included process in programs to control costs of home- and community-based care • Case management was also incorporated in hospital-based demonstration projects funded by a major private foundation to improve health care for older adults • Health care professionals were developing case management systems to improve patient care within the hospital

6. Definition of Case Management • “A collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates the options and services to meet the individual’s needs using communication and available resources to promote quality cost effective outcomes.” • “A system with many elements: health assessment, planning, procurement, delivery and coordination of services, and monitoring to assure that the multiple service needs of the client are met.”

7. Case Management “Coordination” • Case management as: • a service function directed at coordinating existing resources to assure appropriate and continuous care for individuals on a case-by-case basis • a function or service provided to coordinate complex care for selected individuals who are more vulnerable, at greater risk, or involved in more complex problems than most

8. Case Management the coordination of care across care areas, between agencies, and (where possible) extending into wellness a function, service, or program for selected individuals who are more vulnerable, at > risk, or involve more complicated problems than most the clinical function Care Management the care delivery within a unit or area of care the organization and management of the entire system of care at the patient/client level Case vs. Care Management

9. Case Management vs. U.R. • Case Management • primary focus to maintain quality of care as the patient moves through varying levels of care as his condition changes • not needed in every case, but only in a select few or in those in which the quality of care can be or is an issue • U.R. • primary focus is to provide a means of monitoring unnecessary services and containing costs • involves prior authorization, preadmission screening, or concurrent review

10. Case Management Core Functions • Case management is often defined by its core function - but WHAT IS IT??? • Administrative function or a Service? • UR or QA approach? • Fiscal or Clinical model? • Hospital or Community-based activity? • Nurse, Social Work, Physician responsibility or Patient, Family, Client responsibility?

11. Case Management Objectives • Depend on: • the organization’s perspective and the design of the case management system • the population served and its health status • the type of case management allowed or offered by an organization • the case manager’s level of expertise • the method by which case management is linked to the organization

12. Case Management Components • Case identification and eligibility determination • Assessment or evaluation • Care plan development • Implementation or coordination • Follow-up • monitoring • reassessment • discharge

13. Case Identification • Efforts to define and target the desired population • includes outreach activities that publicize the services and identify referral sources • determining the eligibility and appropriateness for case management is achieved through established intake procedures: • acceptance for services may be based on criteria like age, income, diagnosis, acuity, high risk, or high cost • eligibility may be mandated by a payer or be set by the case management program • referrals can be made by phone, in writing, or through in-person screenings

14. Assessment • Determines the needs and provides information to develop an individual care plan • may be conducted by an individual case manager (e.g., social worker or nurse) or by a multidisciplinary team • multiple instruments are used • questions address physical and mental health, functional ability, family and social supports, home environment, and financial resources • family members, physician, friends, service providers, and attorneys may be interviewed • goal is to get a complete view of the individual and their circumstances

15. Care Plan • Developed to address the needs and problems identified in the assessment • includes agreement with the individual and involved family members on goals and priorities • outlines the problems,type and level of assistance needed, the roles of the patient/client and family who will provide the services and desired outcomes • knowledge of service options, local resources, delivery systems, qualified providers, financial alternatives, available benefits, and eligibility requirements for assistance are critical to the plan

16. Service Coordination • Arranging and coordinating service delivery • includes coordinating informal assistance, such as that provided by family members, and facilitating transitions between services or settings • case managers authority depends upon the program and the payer • the case manager’s knowledge of the service system, expertise in establishing relationships with providers, and ability to work with the patients/clients and families to make decisions and accept services are key to the successful implementation of the care plan

17. Follow-Up • Activities conducted to ensure continuity, to respond to changes in the individual’s condition, and to address any problems in care delivery • setting determines thenature and duration of the task • monitoring services to determine their continued effectiveness and appropriateness; also an important cost containment measure • contact with the individual, family, and service agencies to reduce problems and avert crises • formal reassessment to ensure the health care plan remains relevant

18. Other Functions • Education and training of the patients/clients and caregivers • Advocacy with agencies and providers for services or benefits • Counseling • Problem solving • UR, QA, and professional consultation are often combined with the CM function

19. Case Management • Not a field, discipline, or profession, but a locus of responsibility carried by many different people • professionals, paraprofessionals, volunteers, family members, and sometimes, patients/clients themselves • Focuses on a set of tasks and activities that demand considerable knowledge and skills requiring professional intervention

20. Case Management • Makes the health care system work • by ensuring that the patient is at the right level of care at the right time in his/her illness or injury, and • by encouraging a high quality of care at the correct price

21. The Case Manager • Serves as a partner or team member, working with patients/clients; involving many members of natural support systems such as family, friends, and neighbors; and engaging professionals, such as physicians, attorneys, and home care providers. • Often works in multidisciplinary teams, bringing health and psychosocial expertise and perspectives together • Performs in many roles

22. The Case Manager • Can be found in any number of settings including: • hospitals, skilled nursing facilities, assisted living, independent case management practice, outpatient, day care, rehab programs, physician practices, health plans, workers’ comp and managed care organizations • It is not uncommon to find a case manager from the health care setting and one from the payor site working together to meet the patient’s needs

23. Case Management Program Design

24. Case Management Program Design

25. Demographics Affecting CM • Approximately 20% of the insured population uses the benefits of case management, and of this number, approximately 3-5% consume 80% of the total health care $ spent • Most cases classified as “catastrophic” have a potential claim $ expenditure of more than $100,000 in the initial episode of care • Approximately 10% of all births belong in the “catastrophic” category

26. Demographics Affecting CM • Although much can be done by phone, high-quality case management is best accomplished by using a combination of on-site intervention and monitoring and phone communication and by separating utilization or discharge coordination review responsibility from case management • On-site case intervention and involvement allow greater cost savings and ensure that the patient receives the right care in the right place at the right time, but it is labor intensive and requires adequate personnel

27. Demographics Affecting CM • Confidentiality, patient rights, and privacy must be maintained at all times, and only reasonable and lawful means must be used to collect information • Caseloads depend on such factors as the type of case management offered, the assigned duties of the case manager, the type of clients or population served by the health care organization, the qualifications and expertise of the case manager, the acuity of care and needs of the patient, and any other demands placed on case managers by senior management

28. Demographics Affecting CM • Case closure occurs when it is thought that the case no longer poses a risk to the health care organization; cases remain open from 2-6 months or longer • Some mechanism of documentation of case events is of critical importance because of the length of time the cases are open; also, some form of documentation is required for the protection of the case manager and the organization should the case proceed to litigation • Cost savings reports, case time, and case summaries are considered to be 3 important management tools

29. Demographics Affecting CM • Finding qualified nurses to serve in the role of case managers is difficult because most firms require both recent acute care experience and a knowledge of community resources • Ongoing inservice training and education of nurses is necessary and must occur on a regular and frequent basis • New case managers require monitoring for several months or until they can manage a caseload adequately

30. Factors Affecting Cases • Age of patient • Family dynamics or problems, marital status, family or support systems • Social or ethnic background • Recent other life crisis (retirement, divorce, death) • Adequacy of treatment plan, facility, or agency to manage the level of care • Medical history and premorbid or personality type of the patient

31. Factors Affecting Cases • The patient’s or family’s motivation and compliance with the treatment plan • Physical deterioration and level of dependence or independence prior to the illness or injury • Psychiatric history, psychological or emotional stability of both the patient and the family • Physical or mental ability of the patient or family, including ability to understand and be trained • Standards of care for the community or region

32. Factors Affecting Cases • Availability of resources • Financial capability to assume out-of-pocket expenses • Eligibility for alternative funding programs, as well as the waiting time between application and enrollment into the program • Level of acceptance of the condition by both patient and family • Number of small children in the home

33. Factors Affecting Cases • If trauma is involved, the number of persons involved and the severity of their injuries • If a small child is involved, the age and maturity of the parents • Adequacy, timeliness, and extent of discharge planning and level of expertise of the discharge planner

34. Administrative Concerns • Accountability • accountable to the recipient of the care, family members, the service providers, and whoever signs their paychecks • Information Systems • information about case management systems has not yet been achieved • Location/Position • important design decision; will affect status, utilization, and acceptance by internal and external entities

35. Professional Issues • Standards • important to assure ethical, moral, and professional behavior and practice • Quality Assurance • difficult issue to address is how to assure quality of case management because it is more of a process than an outcome and its functions are not always clear • Education/Certification • somewhat controversial because no consensus on standards, curriculum, or need for a separate degree or credential

36. Professional Issues • Integration • goal of many organizations is integration of acute and LTC or medical and nonmedical services • Provider vs. Independent • conflict of interest for the case manager as the coordinator of services, to also be part of the provider for care

37. Case Management Programs • Medical Case Management Programs • Community Nursing Demonstration • Home Health Care Programs • Nonmedical Case Management Programs • The National Long-Term Care Channeling Demonstration • 2176 Medicaid Waiver Program • Integrated Case Management Programs • On-Lok/PACE Replications • Social HMO (S/HMO)

38. Benefits of Case Management • Increased Satisfaction of patients and families • Fits well with the principles of managed care • Effective cost containment strategy • Well-suited for use across the full continuum of care

39. Most Common Diagnoses • AIDS • Terminal cancer, end-stage diseases that have the potential to result in long-term care • Ventilator dependence or dependence on other technological assistance • Neurological disorders or trauma, spinal cord injuries, or traumatic brain injuries • Transplants • Neonates • Technologically dependent children or children with multiple congenital anomalies

40. Conclusion • Case management will continue to be the preferred approach to service delivery as long as complex financing and regulations, fragmentation, duplication, and gaps remain. • Case management is becoming increasingly important as the growth in continuum of care systems develop.