Introduction to
Case Management
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 selfdetermination.”
http://www.acmaweb.org/
Case Management Settings
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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
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•
•
•
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
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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.
Corporate Compliance
Committees
• List the Director of Audit Services and Corporate
Compliance and their Contact Information, per
facility.
• List the Corporate Responsibility Officer, and their
Contact Information, per facility.
Corporate Compliance Hotline
• List the Compliance Hotline Number, per
facility.
• Anonymous reporting
• Available 24/7
Corporate Compliance
• Include hospital specific education or booklet
information.
• List the Corporate Values per facility
• HIPAA
• Ask yourself- “Is it the right thing to do?”
Financial Responsibility of the
Case Manager
• Case Managers must learn to balance the needs
of the patient with the institution’s goals and
practices.
• Conflict arises when there is a clash in the
values of the Case Managers, patients,
physicians, and the facility.
Case Management: Quantifying
It’s Impact on Hospital Outcomes
Outcomes that CM Impacts
• Reductions in:
• Readmissions
• Length of stay
• Avoidable days/delays
• Patients staying over the weekend unnecessarily
• Outpatient diagnostics
• Increases in:
• Physician satisfaction
• Case mix index
• Pre-admission services
Outcomes that CM Impacts
Case Management can show “soft” and “hard”
savings.
• Examples of “hard” savings are directly linked to Case
Management. Examples would be reduction in payer
denials or decrease in avoidable days.
• Examples of “soft” savings are indirectly linked to
Case Management such as lower readmission rates
or lower post-op complication rates. These can be
converted into dollars.
References
• American Case Management Association (2007). Standards
of Practice & Scope of Services. http://www.acmaweb.org/
• American Nurses Association (2001). Code of ethics for
nurses with interpretive statements. Available online at
http://www.nursingworld.org/ethics/code/protected_nwcoe30
3.htm
• Case Management Society of America
• Reference state statutes
• Joint Commission Accreditation of Hospital Organizations
(2007) Standards of Practice Manual.
• Webb (2006). Ethical theories and principles. Unpublished
Manuscript, University of South Florida, Tampa.
References (Cont’d)
• http://www.acmaweb.org/
• http://www.ccmcertification.org/
• http://www.socialworkers.org/
• http://www.cmsa.org/
• http://www.sswlhc.org/
• http://www.cms.hhs.gov/
Review Questions
1. Case Management is defined as:
a. A collaborative process.
b. The coordination of care across the
continuum.
c. A mechanism to provide services at the right
time and the correct setting.
d. All of the above.
Review Questions
2. The Scope of Case Management Services
include (but are not limited to) the following:
a.
b.
c.
d.
e.
f.
Provision of care.
Advocacy and Education.
Clinical Care Coordination/Facilitation.
Financial Management.
A only.
B,C, and D.
Review Questions
3. Level of Care Appropriateness is an example
of which ACMA service category:
a. Clinical Care Coordination/Facilitation.
b. Performance and Outcomes Management.
c. Utilization Management.
Review Questions
4. True or False
A patient has the right to self-determination, even
if the care provider does not agree with the
decision.
Answer Key
Question 1
Question 2
Question 3
Question 4
D
F
C
True