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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.

 

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Should you have any further questions regarding this article, please direct your questions or comments to "Ask the Doctor" section.

 

Copyright © 2004 - 2012Taras V. Kochno, M.D.  All Rights Reserved
Board Certified in Physical Medicine and Rehabilitation

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