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Case
Management in Subacute Settings
Case management systems have
undergone dramatic changes to adapt to the ever-evolving health care
system restructuring. Previously considered primarily an extension of
social work, it now requires a thorough clinical, financial,
administrative, and psycho-social understanding.
In the past years, many definitions have been offered for case management.
In an attempt to have a consensual agreement, the National Task Force on
Case Management presented its definition, "Case Management is a
collaboration process that assesses, plans, implements, coordinates,
monitors, and evaluates services necessary to meet an individual's needs
with the use of communication and available resources to promote high
quality, cost-effective outcomes." (American Health Care Association,
1994) Various case management models are utilized to meet the specific
needs of health care. Episodic case management offers the best suited
model for the subacute setting.
This model provides health care
services by one or more caregivers as a result of an episodic illness,
injury, or condition. The case manager in subacute settings has two
primary roles.
The first role is to establish and
ensure a viable treatment plan within the allotted resources to accomplish
successful functional outcomes and discharge.
The second role involves analysis of
outliers or variances in order to learn how to predict and prevent them
from recurring. The objective of case management is to manage the
effective and efficient utilization of resources within existing
constraints to ensure that each individual patient achieves his/her
optimal medical and functional level.
In developing a case management system, the system must ensure that all
patients receive the highest quality of comprehensive health care services
in a timely, cost-effective, and outcome-oriented manner.
The case management system should be designed to be
flexible and responsive to the ever-changing needs of die patient, family,
third-party payer, community, referral source, physician, and employer.
The
objectives of case management are to proactively coordinate the following:
1. Quality programming which is designed to
respond to each individual patient's needs.
2. Monitor, in a cost-effective manner, service delivery to insure
progress toward functional outcomes.
3. Provide efficient discharge planning to insure
optimal recovery through a continuum of care via community and home health
services.
4. Collect clinical data throughout the patient's hospitalization and post
discharge in order to monitor the effectiveness and efficiency of all
services.
5. Work closely with external case managers, payers, and third party
administrators to consistently insure outcome-oriented, cost-efficient
care and customer satisfaction.
As managed care takes on a dominating role in health care expenditure, the
case manager takes on an important role to provide an accurate projected
cost plan.
These cost plans are used to
determine the level of care, clinical services, and resources such as
medication and equipment needs. The projected cost plan differs from that
of a preliminary clinical care plan.
The clinical care plan incorporates
medical necessity, clinical goals, and anticipated functional outcomes;
whereas, the projected cost plan does not address this. On the other hand,
the projected cost plan identifies intensity of the professional services
to be used and projects an anticipated cost to the payer based on an
estimated length of stay for the individual patient.
Therefore, the projected cost plan requires constant communication between
financial and clinical services. It is the role of the case manager,
in coordination with the program director, to provide projected valid
clinical outcomes, based on service intensity and length of stay, and to
predict an anticipated cost for this service.
It is the role of the business
office to review this information and to obtain from the payer written
verification of pre-certification, which is essential to document what
out-of-contract agreements have been made.
The more complex projected cost
plans are often accompanied by a preliminary care plan.
The case manager is the
interdisciplinary team member who serves as a key liaison between the
treatment team, patient/family, referral source, and the payer. The
duties and responsibilities may be segmented into three stages which
correspond to the pre-admission, admission/treatment, and discharge.
In the pre-admission stage, the case
manager assists in identifying the appropriateness of the patient claim
based on specific admission criteria for each specific program. The next
step involves developing a pre-admission financial analysis, resource
estimation, and cost projection, based on a projected length of stay.
This projection should include a realistic and appropriate plan for
discharge which includes disposition. The case Manager then introduces the
specific subacute programmatic care plan to the patient and family that
includes predicted clinical and financial expectations.
In the admission and treatment
stage, the case manager continuously reviews resource and cost allotments,
while coordinating the treatment plan specific to the individual patient's
needs. Through interdisciplinary team staffing conferences, weekly or
biweekly, the case manager reassesses and establishes the short and
long-term goals for each patient.
Throughout the inpatient stay, the case manager communicates to the
patient, family, referring facility, and external case manager on a
regular basis with specific focus on problems, progress, length of stay,
and discharge plan. The case manager is also responsible to develop an
evaluation process that analyzes patient care in regard to quality,
clinical and financial satisfaction, and complications via an ongoing
monitoring tool.
In the discharge stage, the case
manager in coordination with the treatment team ensures that comprehensive
discharge planning, equipment needs, patient and family
teaching/education, and follow-up services are provided.
The case manager assists in
resolving any outstanding issues related to patient care that may have
occurred during the inpatient stay. Finally, patient and family
satisfaction surveys are conducted to obtain information regarding their
perceptions on the quality of care and outcomes.
As stated, the objective of case management is to manage the effective and
efficient utilization of resources within the existing constraints to
assure that each individual patient achieves his/her optimal medical and
functional level. It is vital that the case manager be effective in
his/her role as the focal point of communication for all involved in the
treatment process.
Effective communication is essential for the success of the case
management process. This function impacts future referrals, repeat
contract business, customer satisfaction, and reputation. No matter what
the quality of the services provided, if the quality is not evident
through communication with the customer, these services will not be used.
Should you have any further questions
regarding this article, please direct your questions or comments to "Ask
the Doctor" section.
Copyright © 2004 - 2008 Taras V.
Kochno, M.D. All Rights Reserved
Board Certified in
Physical Medicine and Rehabilitation
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