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
DEStech – :
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
DEStech – :
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