The Case Manager’s Survival Guide

Winning Strategies in the New Healthcare Environment

Third Edition

Toni G. Cesta, Ph.D., RN, FAAN and Hussein M. Tahan, Ph.D., RN

978-1-60595-288-8, August 2016, 522 pages, 8.5 x 11, Soft cover or Online book.

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  • Revised, updated, expanded edition of essential textbook for healthcare leaders, case managers, nurses, social workers, and other professionals
  • New information on the ACA, value-based purchasing, accountable care organizations, emerging reimbursement methods, transitions of care, changing accreditation standards and much more
  • A proven textbook for university courses, case management certification exam prep, competency development, professional development, and continuing education
  • Numerous case management models, case studies and real-world examples, financial tools and formulas, practical pointers and sample problems, and select job descriptions used in various case management practice settings

The third edition of this important textbook adds over 10 years of new data, facts and experience needed by professional case managers, program administrators or leaders, and students of case management. The new edition incorporates the impacts of the Patient Protection and Affordable Care Act, value-based purchasing methods, care coordination strategies, transition planning, and case management software. Like the previous editions, this textbook is written to assist the professional and student, especially in the field of nursing, social work, and other health disciplines with practical guidance for understanding and mastering the techniques of managing patients in multiple healthcare settings: pre-acute, acute, and post-acute as well as payer-based. At once practical and comprehensive, this new and expanded edition provides recent financial, legal and care provision information required by case managers to succeed in the evolving environment of healthcare delivery. The result is an essential resource for individuals and interdisciplinary care teams from many professional backgrounds, who can use the know-how in this textbook for coordinating care, containing costs, and improving quality, safety and optimizing the patient experience. The Case Manager’s Survival Guide is also a proven textbook, used by hundreds of instructors and students in university and continuing education courses, as well as by those preparing for case management specialty certification, and for advancing their professional careers.

Foreword

Preface

 

Chapter 1. Introduction to Case Management

1.1 Using this Guide

1.2 Healthcare Industry under Healthcare Reform

1.3 Value-Based Purchasing

1.4 History of Case Management

1.5 Changes in Reimbursement: The Driving Force Behind Case Management

1.6 The Cost/Quality Ratio

1.7 Nursing Case Management

1.8 Early Community-based Case Management

1.9 History of Evidence-based Guidelines

1.10 Case Management Plans Today

1.11 Multidisciplinary Care Planning

1.12 Choosing a Case Management Tool

1.13 Physician Support

1.14 Benefits of Case Management

1.15 Interdisciplinary Team

1.16 Change Process

1.17 Managed Care

1.18 Key Points

1.19 References

 

Chapter 2. Financial Reimbursement Systems

2.1 Origins of the Prospective Payment System: An Overview

2.2 Use of Documentation

2.3 Impact of DRGs on the Healthcare Industry

2.4 Use of Diagnosis-related Groups Today

2.5 Observation Status

2.6 The Two-midnight Rule

2.7 Ambulatory Payment Classifications: Medicare’s Outpatient Prospective Payment System

2.8 Home Care Prospective Payment System

2.9 Inpatient Rehabilitation Facility Prospective Payment System

2.10 Long-term Care Reimbursement (Skilled Nursing Facility)

2.11 Government Programs

2.12 Third-party Payers/Managed Care Organizations

2.13 Managed Care and Its Stages of Development/Maturation

2.14 Integrated Delivery Systems as a Response to Managed Care

2.15 Other Health Benefit Plans

2.16 Proactive Tactics to Counteract the Effects of Managed Care

2.17 Value-Based Purchasing

2.18 Key Points

2.19 References

 

Chapter 3. Case Management Models

3.1 Systemness and Case Management

3.2 Types of Case Management

3.3 Pre-Acute Care Models

3.4 Health Homes

3.5 Managed Care Models and Case Management

3.6 Wellness, Screening, and Prevention

3.7 Acute Care Case Management Models

3.8 State-of the-art Acute Care Case Management Models

3.9 Post-Acute Care Models

3.10 Long-term Care Case Management

3.11 Sub-Acute Care Case Management

3.12 Acute Rehabilitation

3.13 Palliative Care

3.14 Hospice Care

3.15 Chronic Care Case Management

3.16 Designing Case Management Models

3.17 Setting Up the Case Management Program

3.18 Key Points

3.19 References

 

Chapter 4. Role of the Case Manager

4.1 Case Management Process

4.2 Various Roles Played by Case Managers

4.3 Roles of the Case Manager in Varied Settings

4.4 The Social Worker as Case Manager

4.5 The Advanced Practice Registered Nurse as Case Manager

4.6 A Day in the Life of the Case Manager

4.7 Organizing Your Day as a Case Manager

4.8 Interdisciplinary Patient Care Management Rounds

4.9 Success in the Role of Case Manager

4.10 Key Points

4.11 References

 

Chapter 5. Utilization Management

5.1 Relationship Between Utilization Management and Case Management

5.2 The Review and Certification Process

5.3 Criteria Used for Utilization Review

5.4 Criteria Used for Utilization Review—Integral

5.5 The Continuum of Care

5.6 MCG-Milliman Care Guidelines

5.7 Denials and Appeals

5.8 Government Contractors

5.9 Quality Improvement Organizations

5.10 What Case Managers Need to Know About Managed Care Contracts

5.11 Working with Patient Accounts

5.12 Reporting Utilization Management Data

5.13 Conditions of Participation—Utilization Review

5.14 National and Local Coverage Determinations

5.15 The Two-midnight Rule

5.16 Role of the Physician Advisor

5.17 Key Points

5.18 References

 

Chapter 6. Transitional and Discharge Planning

6.1 Transitional Planning or Discharge Planning

6.2 The Continuum of Care

6.3 The Case Manager’s Role in Transitional Planning

6.4 Transferring Patients to Other Facilities

6.5 Successful, Safe, and Quality Transitions of Care

6.6 Key Points

6.7 References

 

Chapter 7. Skills for Successful Case Management

7.1 Nursing and Case Management Processes

7.2 Leadership Skills and Functions

7.3 Communication and Other Interpersonal Skills

7.4 Communication Paths

7.5 Successful Leaders

7.6 Key Points

7.7 References

 

Chapter 8. Case Manager’s Documentation

8.1 Importance of Documentation

8.2 Electronic Medical Records

8.3 Case Management Software Applications

8.4 Role of Case Managers in Documentation

8.5 Charting by Exception

8.6 Timing and Frequency of Documentation

8.7 Documenting Patient Education

8.8 Case Presentations

8.9 Key Points

8.10 References

8.11 Appendix 8.1

 

Chapter 9. Becoming a Case Manager: Training, Education, Certification, and Job Seeking

9.1 Background of Case Management Educational Programs

9.2 Case Management Certificate Programs

9.3 Case Management Non-Certificate Programs Organization-Based

9.4 Case Management Academic Degreegranting Programs

9.5 Organization-Based Orientation of Case Managers

9.6 Case Management Certifications

9.7 The Commission for Case Manager Certification

9.8 The American Nurses Credentialing Center’s Nursing Case Management Certification

9.9 The National Association of Social Work Case Management Certification

9.10 Forecasting the Future of Case Management Credentialing

9.11 Hiring Case Managers

9.12 Candidates for the Case Manager Role

9.13 Characteristics Looked for in Potential Candidates for the Case Manager’s Role

9.14 Interviewer’s Role

9.15 Follow-up Interviews

9.16 Key Points

9.17 References

 

Chapter 10. Case Management Plans of Care

10.1 Overview of Case Management Plans

10.2 Types of Case Management Plans

10.3 Process of Developing Case Management Plans

10.4 Patient and Family Case Management Plans

10.5 Strategies for Physician Participation and Buy-in

10.6 Organizing the Work of the Interdisciplinary Team

10.7 Key Points

10.8 References

10.9 Appendix 10.1

 

Chapter 11. Quality and Safe Patient Care

11.1 Importance of Quality

11.2 Meaning of Quality

11.3 Characteristics of Quality

11.4 Setting the Standards for Quality and Safety

11.5 A Historical Review of Quality and Safety

11.6 Using Structure/Process/Outcomes to Measure Quality

11.7 Quality Categories of Organizational Values

11.8 Case Management and Continuous Quality Improvement

11.9 Consumer/Patient Experience and Satisfaction

11.10 Hospital Value-Based Purchasing

11.11 Meaningful Use

11.12 Cost/Quality/Case Management

11.13 Case Management and Outcomes Management

11.14 Modern View of Quality and Safety

11.15 Key Points

11.16 References

 

Chapter 12. Measuring the Effectiveness of Case Management

12.1 Outcomes as Indices of Quality

12.2 Quality Outcome Metrics

12.3 Financial Outcome Metrics

12.4 Productivity and Regulatory Metrics

12.5 Clinical Outcomes

12.6 Patient Care Variances

12.7 Outcomes Management and Outcomes Classification

12.8 Organization-Specific Outcome Measures—Evaluating the Department of Case Management

12.9 Report Cards

12.10 Organization-Specific Outcome Measures—Evaluating the Case Manager

12.11 National Quality Indicators

12.12 Key Points

12.13 References

 

Chapter 13. Application of Legal Concepts and Issues in Case Management Practice

13.1 Case Management Systems, The Case Manager and the Legal Process

13.2 Sources of Anxiety for Today’s Case Managers

13.3 Basis for Assigning Liability in Case Management

13.4 The Difference Between Negligence and Malpractice

13.5 Establishing the Standard of Care for the Case Manager

13.6 Standardized Case Management Plans of Care

13.7 Informed Consent

13.8 Patient Confidentiality

13.9 Case Management “Hot Spots” that have Already Received Legal Review

13.10 Nonadherence/Mismanagement

13.11 Documentation

13.12 Legal and Ethical Dilemmas for the Case Manager

13.13 Role of the Medical Record Review in a Lawsuit

13.14 Professional Misconduct

13.15 Risk Management

13.16 Protecting the Case Manager in a Litigious Society

13.17 Key Points

13.18 References

 

Chapter 14. Ethical Issues and Standards in Case Management

14.1 Commercial Health Insurance, Managed Care, and Patient Advocacy

14.2 Case Management and New Ethical Challenges

14.3 Maintaining Ethical Integrity

14.4 The Deliberative Framework

14.5 Organizational Ethics

14.6 Ethical Framework for Shared Decision Making

14.7 General Ethical Principles Applicable to Case Management

14.8 Key Points

14.9 References

 

Chapter 15. Accreditation in Case Management

15.1 Patient-Focused Standards

15.2 Organizational Functions

15.3 Continuous Self-Evaluation and Improvement

15.4 Continuous Self-Evaluation and Improvement

15.5 Relationship of Case Management to Accreditation Standards

15.6 Case Management and Root Cause Analysis

15.7 Documentation Standards

15.8 Interdisciplinary Approach to Patient Care

15.9 The National Committee for Quality Assurance

15.10 Utilization Review Accreditation Commission

15.11 The Joint Commission

15.12 Key Points

15.13 References

 

Chapter 16. Using the Internet and Digital Tools in Case Management

16.1 The Internet

16.2 Patient and Family Education Resources

16.3 Other Uses of the Internet by Case Managers

16.4 Assessing the Quality of Health Information on the Internet

16.5 Social Media and Digital Tools

16.6 Personal Health Records

16.7 Patient Activation, Engagement and Use of Technology

16.8 Case Management-Related Websites

16.9 Key Points

16.10 References

Appendix I: Sample Job Descriptions

Appendix II: Sample Performance Appraisals/Review

 Index

About the Authors

  1. :

    The Case Manager’s Survival Guide brings our attention to the crucial issues facing case managers today, while providing real time solutions. This book updates and extends the understanding of the role of the case manager in an ever changing healthcare environment. The information in ACA, value-based purchasing, accountable care organizations and understanding reimbursement, just to name a few- make this a must read for even the most experienced case manager.

    Pat Wilson, MBA, BSN, RN
    AVP, Transplant Services

  2. :

    When entering the space of case management, few would begin to imagine the myriad of complexities and diverse scenarios one would face as a case manager. And so often, what we read about case management is not current and relevant to one’s field of practice. That is why this book is applicable for the new and experienced case manager, and whether working in acute, post acute and the various ambulatory settings. Each of these setting have their unique set of challenges and responsibilities, so you can easily find the area in the manual that is pertinent to you. This guide is structured in a format that is easy to navigate with practical tips and examples that is targeted for these various workplaces. Helpful information is included to address organizational opportunities and nuances. And, with the changing landscape of healthcare, such as new payment methodologies, new governmental compliance regulations, a more savvy consumer as your patient, etc., the authors provide strategies and recommendations to assist in optimizing resources, reimbursement, staff development, patient experience and overall transitions of care. Today, we find case management concepts and outcomes gaining C-suite attention as we emerge into value based care and continuously strive to improve the quality of care for our patients. This comprehensive book includes all facets of case management, from job descriptions to documentation, and will give you a better appreciation and understanding of the role of case management as it applies to nursing, the revenue cycle and overall delivery of care.

    Yvonne Focke, RN, BSN, MBA, ACM, Case Management Consultant

Toni G. Cesta, Ph.D., RN, FAAN is a founding partner of Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating case management models in the acute care, emergency department and outpatient settings. Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management newsletter in which she shares insights and information on current issues and trends in case management.

 

Hussein M. Tahan, PhD, RN, is the system VP of nursing professional development and workforce planning at MedStar Health, Columbia, Maryland. Hussein has more than 25 years of experience in healthcare. He is a past commissioner and chair of the Commission for Case Manager Certification (CCMC) and currently a member of the editorial board of Professional Case Management. Hussein has a strong publication, public speaking and research record in case management, care coordination and transitions of care. He is a coauthor of the CMSA’s Core Curriculum for Case Management, 3rd Edition, knowledge editor of CCMC’s peer-reviewed Case Management Body of Knowledge online portal, and has participated on various national taskforces on healthcare issues including case management. Hussein is also the recipient of the 2016 Case Management Society of America’s Lifetime Achievement Award for his work in the field of case management.

978-1-60595-288-8, August 2016, 522 pages, 8.5 x 11, Soft cover or Online book.

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