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79 Cards in this Set

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The discharge process includes, but is not limited to:
Planning.
Teamwork.
Contingency Plans / Access to Medical Care.
Responsibility / Accountability.
Communication.
Tools.
The discharge process
Planning
When planning for transition or discharge, the health care professional must plan the discharge based on a comprehensive assessment of the patient's physiological, psychological, social, and functional needs.

The discharge planning process should begin early in the course of treatment for illness or injury with involvement of patient, family and physicians from the beginning.
The discharge process
Teamwork.
Planning for discharge with the collaboration of the entire team, which generally consists of the patient, the family, the physician with primary responsibility for continuing care of the patient, and other appropriate health care professionals as needed, can ensure that the discharge plan will run smoothly.
The discharge process
Contingency Plans / Access to Medical Care
Plans for unforeseen events must be in place prior to the transition to settings with limited resources.

Patients and caregivers must be conscientious of all the possible signs and symptoms that need to be reported.

They must also have a means of getting the information to the physicians as quickly as possible and receiving instructions from the physicians in a timely manner.
The discharge process
Responsibility / Accountability
When a patient is being transferred from one location to another, the responsibility and accountability fall on the attending physician.

If the attending physician is not present during the transition, the attending physician is responsible to contact the receiving physician and inform him/her of the patient's illness, course, prognosis, and needs for continuing care.

The patient should not be discharged if there is no physician able or willing to care for the patient.

Apart from the responsibility of the attending physician, the health care facility in which the patient is actively being taken care of is also responsible for evaluating the patient's needs and assuring that the current and future needs of the patient can be met in the setting to which the patient is being transferred.
The discharge process
Communication
When transferring the patient, all pertinent information (such as the history and physical examination, record of hospital treatment course, laboratory tests, medications, advanced directives, functional, psychological, social, and other assessments) and the discharge summary should be completed at, or prior to, transferring the patient to the new setting.

Patients should not be accepted in the new setting without a copy of this information and a complete set of instructions for continued care.
The discharge process
Tools.
Many companies which previously only addressed criteria or LOS for acute care inpatient stays or ambulatory surgery centers are now developing criteria for transition to alternative levels of care.

For example, Milliman has Recovery Facility Care and Home Care Guidelines available for case management use.
The following components for a structured discharge process to identify and assure that the patient's needs are met were adopted by the AMA at their 1996 Annual AMA meeting. They were recommended by the AMA Council on Scientific Affairs (PART 1):
• Discharge criteria should be based on data from assessments of physiological, psychological, social and functional needs.

• An interdisciplinary team is necessary for comprehensive planning to meet the patient's needs.

• Early assessment and planning should be organized so that necessary personnel, equipment or training can be arranged in time for discharge.

• Post-discharge medical care requires arrangements (before discharge) for easy access to continuing physician care.

• Patient and caregiver education in meeting post-discharge patient needs should occur prior to discharge. Patients and caregivers should be able to demonstrate their understanding and ability to meet the care needs before discharge.
The following components for a structured discharge process to identify and assure that the patient's needs are met were adopted by the AMA at their 1996 Annual AMA meeting. They were recommended by the AMA Council on Scientific Affairs (PART 2):
• Coordinated, timely and effective communication between all health professionals, caregivers and the patient is essential and should be well established before discharge.

• As tools for planning patients' transitions from one care setting to another and for determining whether patients are ready for the transition, discharge criteria are intended to match patients' care needs to the setting in which their needs can best be met.
Discharge criteria consist of (but are not limited to) the following:
• Objective and subjective assessments of physiologic and symptomatic stability matched to the ability of the discharge setting to monitor and provide care

• Patient's care needs matched with the patient's, family's, or caregiving staff's independent understanding, willingness, and demonstrated performance prior to discharge of processes and procedures of self-care, patient care, or care of dependents

• Patient's functional status and impairments that are matched to the ability of the caregivers and setting to adequately supplement the patient's function

• The need for medical follow-up that is matched with the likelihood that the patient will participate in the follow-up care. Follow up is time-, setting-, and service-dependent. Special considerations must be taken into account to ensure follow-up in vulnerable populations whose access to health care is limited.
According to the American Medical Association (AMA), discharge criteria is defined as
organized, evidence-based guidelines that protect patients' interests in the discharge process by following the principle that the needs of patients must be matched to settings with the ability to meet those needs.
Discharge Planning
assists in finding the correct setting for the patient, once medically stable

helps the case manager or discharge planner ensure that the care plan is safe

assists in determining patient needs

teaching is a key component, as it will help the family understand and be able to perform the needed care.

particularly important that attention is paid to the caregiver, in long-term cases, since this role is and often overlooked

home care case manager must advocate with the payer and, many times, with members of the patient's family, to ensure that respite care is incorporated into the treatment plan to prevent burnout of the caregiver
Utilization Management Modalities
In utilization management, there are four modalities which are commonly used. These include:
length-of-stay (LOS), InterQual, critical pathways, and Milliman
LOS
A basic attempt to controlling costs in health care is through assigning LOS, which is basically the number of days for which a patient should remain in the hospital for a specific illness or diagnosis
LOS has been determined based on two sources
In one, data were calculated from over 4 million hospital discharge records from hospitals that participated in the Professional Activity Study (PAS) of the Commission of Professional and Hospital Activities and were statistically assessed. This statistical data were broken down by the specific year, the hospitalization cause, and by percentile.

Secondly, a risk and severity adjusted national database owned and maintained by Health Care Investment Analysts (HCIA) is also used to assign LOS. The HCIA methodology identifies LOS based on diagnosis, age, comorbid conditions, and geographic regions within the country.
InterQual
is a criteria-based system that includes objective and measurable symptoms and services.

criteria should guide the utilization manager in assessing medical necessity and appropriateness of the level of care.

was first introduced and published in 1978. It consisted of severity of illness/intensity of service criteria

had its beginnings in evaluating appropriateness of admissions and level of service.

It is perhaps the best known and most utilized of all utilization parameters.
InterQual determines the severity of illness as follows:
Data is gathered during the assessment phase and includes any signs and symptoms the patient is exhibiting that reflect a need for acute hospitalization.

An example of this criteria is: Acute/sudden onset = within 24 hours; recent onset = within one week; recently or newly discovered = greater than one week; and newly discovered = new findings during this episode of illness.
InterQual determines the intensity of services as follows
Criteria is used to define the diagnosis and therapeutic interventions for each category being done for the patient in terms of diagnostic identification and treatment.

Examples are: IV fluids, IV/IM analgesics at least every four hours, ventilator assistance, chest tubes, suctioning, IV anticoagulants, initial training for functional mobility with prosthesis, orthotics, assertive devices or splints.
InterQual includes discharge screens as follows:
Parameters indicate the patient's readiness and stability for either discharge home, or transfer to another level of care.

There are two components for this category:
• Clinical/function: These are objective and measurable clinical indicators.
• Options: This essentially prompts the reviewer to look at potential options for alternative treatment. Some prompts include changing from IV to IM or oral medication routes or changing to another level of care.
InterQual determines appropriateness through a review process as follows:
• Preadmission review: This review is initiated prior to admission. The review determines whether the diagnostic services and therapeutic modalities are appropriate and match the level of care.
• Admission Review: This review may often be the initial chart review on a patient. This is done within 24 hours. Progressive hospitals are placing members of the UR team in the ER to complete the review and see that the admission meets criteria.
• Subsequent (Concurrent) Review: This review is done intermittently throughout the hospitalization with a three-day maximum interval between reviews. As the patient nears discharge or transfer to another level of care, the review will be completed more frequently.
• Discharge Review: This review is completed from discharge screenings of the same category used to assess IS and SI. The review is to determine stability for treatment and services at a lesser level of care.
In a discharge interqual review documentation:
discusses why a patient does not meet discharge criteria;

should include progress made since the previous review.

of discharge planning is also important. Premature discharge and subsequent readmission may trigger a review of the first hospital treatment.
Key Differences Between Utilization Management and Case Management
Case management is proactive:

--it is meant to actively identify patients at risk for chronic illness exacerbation and to intervene in a manner that has a positive effect on the outcome; in essence, it is concurrent review.
--The focus here is on a small number of patients at a higher level of intensity, and on medically appropriate care.

Utilization management is reactive:

--the patient presents for service whereby there is already an illness or perception of illness.
--Utilization management focuses on the illness episode, and on a large number of patients at a low level of intensity.
--It utilizes prior authorization and concurrent review to evaluate medical necessity.
Milliman Care Guidelines
are a combination of evidence-based clinical guidelines that span the continuum of care, including chronic care management.

were formerly known as Milliman & Roberts.

Milliman Care Guidelines describe the best practices for treating common conditions in a variety of care settings.

have evolved from a combination of LOS criteria and mini-clinical pathways

original goal was to eliminate nonproductive days while maintaining quality of care.

have evolved into annually updated, evidence-based guidelines which integrates clinical content into a case-management framework.

resulting care plans guide daily workflow with practical patient care information for many different chronic conditions.

approach helps care providers meet disease and case management requirements of regulatory accrediting organizations, while incorporating and flagging HEDIS quality measures and supporting national standards.

incorporate Variance Tracking and Reporting
Milliman Care Guidelines
include Chronic Care, Behavioral Health, Home Care, General Recovery, Recovery Facility Care, Inpatient and Surgical Care, and Ambulatory Care

are a compilation of best practices drawn from the current best medical evidence

purpose is to assist health care professionals in providing quality care by reducing the underuse, overuse and misuse of medical resources.

This reduction is accomplished by: describing the right care, at the right time, at the right place; avoiding care delays; incorporating nationally-recognized quality measures; providing planning tools to coordinate care and anticipate patients' needs; and providing patient education tools.
The Milliman Ambulatory Care, Inpatient and Surgical Care, Recovery Facility Care and Home Care are
closely interrelated.

They describe a cohesive continuum of care in different settings, underscoring how well-managed transitional care — both home care and sub-acute care — along with ambulatory services, can reduce the unnecessary use of scarce and expensive in-hospital acute care resources.
Examples of some the categories in a clinical pathway are:
• Assessment and Evaluation: determination of problem using diagnostic tests, etc, and level of care that is needed

• Treatments: Interventions that must be performed by the health care team

• Consults/Referrals: Other members of the health care team; diagnostic tests; medications

• Activities/Morbidities: This category outlines the patient's allowable activities, diet and nutrition, etc.

• Discharge Planning: This category is ideally begun prior to admission. Teaching/educational interactions are provided as needed to help the family/patient become more independent and self-sufficient for discharge.
Clinical pathways
give a daily plan for a particular illness and sequence all aspects of that care for optimal quality and efficiency.

of all of the utilization modalities, most completely takes into account the total multidisciplinary aspects of patient care

is a multidisciplinary management tool that proactively depicts important events that should take place in a day-to-day sequence

are also written for various timelines of care.

are used in chronic disease in the outpatient setting as well

are used for those diagnoses that are somewhat predictable and fit into a pattern.

The multidisciplinary team prospectively prepares a standardized plan which is used as a template to address the usual needs of a defined client population.

be developed based upon diagnoses with similar patient care needs and should then be organized to help the health care team know what intervention on any given day of a patient's hospitalization is most likely to produce the best outcomes for a given patient population
Care Guidelines
were developed as a tool to chronicle and document the effective, efficient delivery of care; ie, delivery that achieves desired patient care outcomes using an optimal level of resources

goal is to provide patients with the best care possible by assisting providers to identify quality care practices in use today — practices that effectively marshal treatment resources while helping to minimize waste and inefficiency

assume that certain infrastructure, including pre- and post-hospital care services, are available in the local health care delivery system to achieve the Care Guidelines' Goal Lengths of Stay.

often helps identify needed outpatient care services not available in a system or community
Variance Tracking and Reporting
enables users to document interactions with a variety of criteria, including: care pathways, indications for admission/procedure, ambulatory authorizations, and chronic guidelines

is utilized in Milliman
The Chronic Care Guidelines
were developed for Chronic Care Management, using Utilization Review Accreditation Commission (URAC) standards for case management as a model

provides a companion set of patient education materials that are written at a fourth-grade level and can be sent to the patient as part of the intervention.

Have nationally recognized quality measures that have been have been integrated into the Care Guidelines' workflow

measures include those from the Centers for Medicare and Medicaid Services (CMS) Hospital Quality Alliance, NCQA HEDIS and The Joint Commission
Management of complex patients via General Recovery Guidelines
provides expanded decision support for management of comorbidities, multiple illnesses, or unclear diagnoses

provide reliable guidance for very complex clinical situations
The case manager can utilize Milliman and InterQual
to achieve various tracking measures due to the tremendous focus on the need to capture outcomes.

To access products that are linked to nationally recognized, publicly reported Quality Measures (QMs), which provide reminders and opportunities to intervene in quality care issues

for product Evidence Summaries and Annotated Bibliographies, along with their respective reference lists, providing first-hand information on the evidence used to develop these guidelines


NOTE: This information helps the case manager make appropriate care decisions for patients who don't closely match the evidence-based practice, or whose clinical information doesn't neatly fit within established criteria.
Collection and recording of comprehensive patient information is an opportunity to identify specific problems that must be addressed.
For example, assessment of the following key areas allows the case manager to identify patient resources:
• Health Status
• Functional Status
• Psychosocial Status
• Cognitive Function and Mental Health
• Medication Regimen
• Living Conditions and Social Situation
• Support System
• Compliance and Adherence (or noncompliance/nonadherence with treatment plan)
Coordination of resources
is challenging for the case manager.

Multiple resources are required by the ill or injured patient/family/caregiver, despite the fact that third-party payment may be limited or not available.

regarding workers' compensation, will cover these services if they are deemed medically necessary.

rocess begins when the case manager completes an assessment of the patient.
Resource Management, also known as Stewardship
requires extensive coordination, well known to case managers, because care coordination is an integral part of each step in the case management process.

includes screening for benefits eligibility; communicating with the patient and the health care team, especially when benefits in the plan of care are out of alignment; communicating and negotiating with payers regarding the anticipated plan of care; identifying post-discharge needs and benefits; and arranging for post-discharge care and community resources.

encompasses a wide range of definitions, each germane to a specific environment and process
refers to efficiency of time, software, and budgets

in case management is defined as the process of identifying, confirming, coordinating and negotiating benefits and resources for patients, including health care services, products, and direct care
Resource Management, also known as Stewardship from a case manager's perspective involves
negotiating with payers or providers for out-of-benefit coverage for necessary services and products not covered, and identifying and coordinating care, services, and products that are financially possible for the patient/family when no third-party payer exists.
Resource case management can be successful
because of a good data management team,
because a comprehensive rehabilitation plan has been accepted by the payer

because of good clinical practice.

with the CM having the inherent ability to be an excellent resource manager.
Based on patient assessment, the case manager
determines the acuity level of the patient and

defines specific goals for the patient.

Determines how the goals will be achieved and their appropriate timelines involves resource management.
Regarding resource management, the case manager
needs to fully understand the behavioral aspects of the patient/family, requiring social workers to perform resource management for patients in acute care settings.

should balance time spent on resource management with other components of the case management process.

should have a reliable list of current community resources available for continuous reference to reduce stress and maximize efficiency.

are encouraged to participate in local professional meetings and regional chapter groups of national professional organizations, such as the American Nursing Association, Student Nurses Association, Case Management Society of America, or the National Association of Social knowledge base in resource management will continue to grow as he/she matures in the role.
Home medical equipment and supplies can be broadly classified into the following groups of products (part 1):
• Ambulation aids, such as walkers, canes, and crutches
• Bathing and toilet aids, such as shower chairs, tub lifts, hand-held showers, raised toilet seats, and grab bars
• Respiratory equipment, such as oxygen concentrators, cannulas, masks, nebulizers, peak flow monitors, and pulse oximeters
• Beds, such as manually adjusted or electric beds, mattresses, and trapeze bars
• Physical therapy equipment, such as treadmills, stationary bikes, weights, tens units, and continuous passive motion (CPM) machines
Home medical equipment and supplies can be broadly classified into the following groups of products (part 2):
• Wound care equipment, such as low air-loss mattresses and wound care dressings
• Enteral products, such as nutrition pumps, tube feeding/oral nutritional supplements, and gastrostomy feeding tubes
• Wheelchairs and accessories, such as manual and power wheelchairs, seat cushions, and storage compartments
• Personal assistive products, such as reachers, glucose monitoring devices, blood pressure monitors, and portable ramps
There are also many forms of "low-technology" assistive devices. Examples include:
• Zipper pulls and Velcro closures on shirts and pants
• Special feeding utensils, such as large-handled utensils for easier grasping, or with weights to decrease hand tremors
• Reachers, which are pick-up tools to reach low and high areas without bending, stooping, or stretching, or areas that would otherwise be unreachable
• Book holders to assist in holding a book, turning pages, or enlarging letters
• Offset door hinges to make existing doorways wider for a walker or wheelchair
• Grab bars and safety rails, which can be purchased in various lengths and installed near toilets and tubs to assist an individual while using the toilet or bathing
• Portable ramps to assist an individual or the caregiver in accessing raised areas, such as the front door
Community Services
National support groups
encompass care for major illnesses and injuries, such as the American Heart Association and the National Brain Injury Association.

are accessed on the Internet, via national toll-free numbers, and through local chapters.

Major non-profit organizations, such as The Red Cross and The United Way, provide extensive lists of smaller volunteer organizations available in the local area which are usually printed in educational pamphlets intended for consumers.

Religious groups are excellent sources of such lists and include interdenominational organizations that may not be found on other resource lists.
Community Services
Social service agencies
are also an excellent resource for the case manager, but usually require the patient to meet certain eligibility criteria not required by volunteer organizations

are financed by county, state, and federally matched funds, and therefore are not usually as flexible or timely in meeting individual needs as voluntary agencies

provide more intense services over a longer period of time
Public health services
are broadly defined as clinical and social services provided by government funding and available to any citizen within the stated geographic area

have on staff primary care physicians and nurse practitioners who provide community-sensitive services which are free, or offered on a sliding pay scale, to anyone walking through the door

includes medical care; dental care; mental health services; well-child immunizations; adult inoculations to prevent community-acquired diseases, such as influenza and pneumonia; and birth control products/services

Community outreach classes are usually offered on a continuing basis, and provide information about smoking cessation, weight loss, dangers of drug use/abuse, and communicable diseases

NOTE: Examples include public health nurses who visit new mothers to check on the health status of babies and teach new mothers necessary skills, such as safe infant bathing and breast feeding, and outpatient health clinics available in most ties.
DME
available from vendors, home medical equipment companies, home health care agencies providing home medical equipment, and retail pharmacies.

Other providers include social service and volunteer organizations, hospital therapy and outpatient departments, long-term care and nursing home facilities, and consignment shops specializing in second-hand equipment.

If required payment from the patient, the amount required is determined by the provider and by the patient's benefits coverage
The case manager engaged in resource management needs to know the best way for the patient to obtain necessary medical equipment and supplies by
finding the limitations/benefits of coverage for medical equipment and supplies

demonstrating for the insurance company a potential cost savings through prevention

finding what equipment/supplies are authorized, who is the insurer, and who are the authorized area dealers

find If the patient a candidate for a free wheelchair from agencies providing free equipment, such as the Paralyzed Veterans' Association

finding If the patient is eligible for equipment and supplies through county elder services or public health funding

find if the child a candidate to receive equipment and supplies through Children's Medical Services

determine if no resources are available, can the patient's physician recommend a less-expensive or alternative type of equipment or supplies

consider issues that will be in the best interest of the patient, as well as costs associated with the service such as exploring options for trade-ins on equipment when the patient grows and needs a larger wheelchair or bed
The case manager (in regards to DME) must consider issues that will be in the best interest of the patient, as well as costs associated with the service such as
exploring options for trade-ins on equipment when the patient grows and needs a larger wheelchair or bed

Determining if renting the equipment exceeds what the equipment would cost
or a rent/purchase option can be negotiated for the pediatric asthma patient whose long-term use of a nebulizer is uncertain at the time the nebulizer is rented

ask the provider to include the company's return policy on the contract bid

exploring contract options for future equipment, such as a wheelchair lift

exploring a service contract, especially if the equipment will be used or is expected to have useful life beyond the manufacturer's warranty period
Assistive technology (AT)
is another tool of resource management that has rapidly evolved in the health care industry

assists patients with their activities of daily living (ADLs), providing the tools necessary to combat disabilities (including the normal aging process), whether in living, learning, working, or recreational activities

includes any equipment or device that increases the independence of a person with a disability

is a common classification of products required by ill or injured individuals, by children and adults with congenital birth defects, and others in the resource management process

can be considered "high-tech" or "low-tech":
Computers are an example of a high-technology assistive device, performing a myriad of tasks


NOTE: Wheelchairs, prostheses, visual aids, computers, adapted sports equipment, and augmentative communication devices are all included under the term AT
Assistive technology items can be purchased
from medication vendors, large retail drug stores, therapy clinics, specialized stores or catalogs, environmental access specialists, assistive technology providers and service specialists, and durable medical equipment (DME) companies. Some equipment vendors loan equipment for a certain period of time before requiring a purchase.
When ordering medical equipment/supplies for a patient, the case manager
should follow up to ensure that the equipment is delivered in good working order, and the patient and family/caregiver is comfortable operating the equipment or using the supplies

should make sure teaching/training to ensure the patient's safety/health and to prevent an unnecessary hospital re-admission

should make sure family/caregiver has information about the equipment agreement that accompanies each piece of equipment. This information includes how the equipment is to be maintained, and the responsibility of the user to maintain the equipment.

provides family/caregiver with contact information from the equipment manufacturer, and from the agency or company providing the equipment, in case of equipment failure or maintenance is required
Professional Standards Review Organization (PSRO)
In 1975, the US Congress amended the Social Security Act to create this organization

intent of the PSRO was to establish peer review among physicians in an effort to systematically evaluate health care services delivered under Medicare

goal of the committee was to allow each hospital system to govern itself in order to justify appropriate care at the appropriate time, and at the appropriate level of service delivery

the nurses who worked along with physicians on the committees became known as utilization review (UR) nurses

common cost-drivers, just as bed days and levels of service, were justified by a professional committee of peers enacted within each hospital system
When Congress enacted the Prospective Pay System (PPS) in 1983
Medicare reimbursement significantly changed from a fee-for-service approach to a pre-determined price formula through diagnostic related groups (DRGs)

DRGs required hospitals and other providers to become accountable for treating patients at a pre-determined rate, despite the length of stay

utilization nurses played a large role in the pre-authorization of diagnostic tests, procedures, and services
During the advances of utilization management system from 1983
health plans were following the Medicare guidelines and, as such, were beginning to examine the care costs

utilization nurses included activities such as retrospective review, whereby nurses would examine charts on a quarterly basis to determine over-utilization of services and care delivery

if charges from the providers were not supported with appropriate documentation in the medical record, payment was denied by the payer

insurance plans began to send utilization nurses into the hospital setting to perform concurrent reviews of patients' charts while the patients were in the midst of being treated

Physicians were pressured to provide adequate rationale for hospital stays, tests ordered and services provided

utilization review activities became more complicated

Pre-certification, also known as pre-authorization, became well utilized as UR nurses were employed to authorize health care delivery services before the health plan would agree to pay any expenses of care delivery
UM
UR expanded to manage resource allocation in an attempt to improve services and to more efficiently reimburse for services through this process

triggered stepping stone into case management, where via ongoing monitoring, patients who had repeat admissions, major setbacks to their care, or social problems that impeded adherence were triaged by the utilization specialist into case management services

focus can be described as a change from a narrow focus to a more comprehensive approach and increased integration of quality assurance oversight mechanisms into the medical necessity determination and appeals process

allows services to be authorized by insurance companies and payers through a systematic process

modalities encourage fiscally responsible lengths-of-stay and offer the case manager an efficient aid for determining medical necessity as the patient moves through the integrated delivery system.
sophisticated information technology (IT) systems
evolved the ability to develop individualized care plans

provide assistance with risk stratification and patient identification within UM and case management
A letter of medical necessity should include
an introduction of who is requesting the equipment or services
a description of why the equipment or services are needed
the beneficiary's diagnosis or injury as well as the current medical status
Disease management (DM)
is an integral part of today's health care system and often an important link to case management processes in payer and provider settings.

is defined as a vehicle by which improved efficiency in achieving specific outcomes is obtained.
represents a proactive health care delivery approach requiring management of chronic diseases such as asthma, diabetes, cardiovascular disorders, and high-risk pregnancy.

is used to minimize or prevent complications or disease exacerbation that could lead to the use of expensive health care services.

is used to prevent acute disease episodes.
Implementation requires a broad range of skills: pharmacoeconomic techniques and processes may be employed to identify different outcome targets, and an understanding of health system databases is critically important for most programs

Efficiency improvements require an assessment of the health care resource units needed to achieve specific outcome goals within patient populations
One of the principal forces driving adoption of DM programs is
the health systems' interest in better comprehending the cost-outcome relationships for specific diseases

NOTE: This is aided by the understanding and integration of models that identify at-risk patient populations for specific, costly conditions/diseases/illnesses.
One way to understand the differences between traditional case management and the newer model of disease management is to
compare the two models globally:

Case management has evolved from practical application to science by interacting; behavior is changed by asking why and how to improve performance, and technological support is gained to enable research.

Disease management, on the other hand, has evolved into health care from science to application; by looking at research, we seek to change behavior based on that research, and we interact.
components of DM programs
Treatment practice guidelines,

educational programs for prescribers and patients,

formulary modifications

outcomes assessments

modeling disease treatment patterns and outcomes

unique financial arrangements between disease management partners
Carve-out DM programs
companies that specialize in managing specific patient populations or disease states

partnered with managed care companies, assumed partial or full risk when taking on the medical management of their defined patient populations

were very popular in the 1990s; they then waned somewhat in the early 2000s before again dominating the market in more recent years


NOTE: Managed care organizations identify high-cost, chronic conditions that affect certain patient populations and then classify patients according to type of risk. High-risk patients would likely then be targeted in a disease management program, and these patients would be assigned to a case manager.
Tools of the Trade in Today's DM Programs
Treatment guidelines (1):
An integral function of most DM programs

are designed to provide a framework for utilizing therapies to guide care.
are those created from a thorough analysis of health system costs for specific diseases; less useful are the treatment guidelines based only on a consideration of drug acquisition costs.
are based on scientific, accepted, consistent practice in the health care community.
cannot address the specific therapeutic needs of every patient, and they are guidelines (not mandated).
They can be designed for the majority of patients with specific diseases. (Each physician and health care professional is still expected to use independent clinical judgment when providing patient care, since treatment response can vary between patients.)
can be developed by health systems to resolve treatment decisions where there may be clinically equivalent products (eg, some antibiotic or anti-hypertensive classes) or treatment controversies (eg, the respective role of 1st & 2nd line abx)
Tools of the Trade in Today's DM Programs
Treatment guidelines (2):
Depending on the complexity, they may be arranged in a list, or as a treatment algorithm or critical pathway.

When treatment recommendations are developed, they are provided in a manner most effective and useful for shifting provider practice patterns.

Although extensively promoted within the literature and in practice, it should be noted that merely providing them without face-to-face communication may not produce reductions in health system costs or improvements in outcomes following their introduction.

Sometimes "guide" practice to certain medication classes without specifying particular agents; this is done because formulary agents often change.
Tools of the Trade in Today's DM Programs
Formulary modifications:
frequently occur when DM programs are initiated, or just prior to initiation.

are an extension of specific disease treatment guidelines.

Drug safety and effectiveness are primarily considered in initial formulary selection, but cost is also considered.

Again, it is important to emphasize that analyses used in making y modifications should be based on health system cost perspectives, rather than only on drug acquisition cost.

DM programs usually include some form of closed formulary or tiered payment system in order to promote high-quality and low-cost products within health systems.

Pharmacoeconomic analyses can be used for evaluating the association of health system costs with specific products and the outcomes achieved with each product.

This will assist in providing a framework for selecting future formulary choices.
Tools of the Trade in Today's DM Programs
Educational interventions:
Depending on the selected diseases, educational efforts may be primarily aimed at prescribers or at both prescribers and patients.

are stratified by resource use or disease severity.

Educational priority is usually given to providers that care for a large number of MCO patients who are not generally following treatment guidelines.

activities must address geographically diverse provider groups.

Tracking and recording mechanisms must be built into each program to account for educational efforts, and these programs must be continually monitored and adjusted as needed.
Tools of the Trade in Today's DM Programs
Outcomes assessment:
Although extremely important, this element is frequently ignored or overlooked in DM programs.

generally divided into clinical, economic, and humanistic (eg, quality-of-life, patient satisfaction) categories.

When implemented, it is critical to obtain baseline outcomes data so that outcomes can be measured again after treatment guidelines have been implemented.

Many are designed to apply pharmacoeconomic principles in comparing treatment alternatives from a health system perspective

to be appropriate for the disease state, selected outcomes should be measurable end points
Tools of the Trade in Today's DM Programs
Modeling treatment options:
describe relationships between inputs and outcomes.

To be useful, must simplify and extract abstract data elements within disease management.

may be useful in drawing conclusions (or in making predictions) in a pharmacoeconomic analysis.
used to simplify complex data elements, models are used.

summarize the principal treatments used in the management of the disease, the process of care along each treatment pathway, the total health care resource units involved in providing care for each pathway, and the outcome (eg, clinical outcomes, such as the number of cures) achieved with each pathway.
Tools of the Trade in Today's DM Programs
Unique financial arrangements:
Risk-sharing or capped arrangement between the DM company and MCOs based on total health costs and outcomes measures to be achieved in patient populations is the most comprehensive financial arrangement from a health system perspective.
Objectives of a DM program are to:
• Ensure cost-effective services that are provided in the most appropriate setting, while optimizing quality and timeliness
• Optimize plan expenditures with decisions based upon utilization management (UM), case management, and quality management (QM) processes
• Facilitate partnering with managed care network providers to maintain quality, improve adherence, promote patient/family education, and achieve patient satisfaction
• Use statistical methods to measure processes, system performance, and results
Pharmacy capitation arrangements
are most familiar to pharmacy directors

capitation agreements have some type of drug capitation plus a focus on specific resource utilization patterns (eg, reducing emergency department visits by asthma patients).

arrangements are much more limited, as these only consider drug costs per member per month and do not consider other health system issues

this type of arrangement may not be in the best interest of the health system, as it does not consider the potential impact on other budgets

arrangements may or may not include outcomes assessment

NOTE: Most DM agreements are risk-based, and the level of risk and reward may vary depending upon the structure of the arrangement. For example, an arrangement based on producing a reduction in emergency department visits or hospitalizations for patients with asthma does not include clinical end points. However, the arrangement may instead be based upon achieving a clinical outcome (peak flow readings ) and and a reduction in resource uses
A common element of negotiations between MCOs and DM companies is risk-sharing arrangements:
If a DM company is able to reduce an MCO's total health care costs for a disease, the partners usually agree contractually to share the savings.

On the other hand, if the costs of providing care remain the same (or rise), or there is a deterioration in clinical outcomes, the DM company may not be paid.
effective drug management program developed within DM
offers clinical pharmacological interventions, improves patient medication adherence, documents and monitors patient outcomes, and builds and improves patient empowerment


achieved by a variety of unique programs designed for specific populations, such as nonadherent patients, and appropriately intervening before the nonadherence becomes a problem

employ the principles of "drug state management" to avoid polypharmacy and other costly problems associated with medication use

implemented due to prescription medications and nonadherence cost the nation's economy an estimated $100 billion annually in additional health care costs

key component of DM models
Medication adherence programs
identify high-risk nonadherent patients by combining medication regimen analyses and patient self-reports with specific program learning data.

Appropriate patient-specific strategies are then developed to modify nonadherent behavior. Health care providers are kept informed of patient progress and are alerted to significant nonadherence.
DM goal
early intervention

to promote cost-effective delivery of clinical and psychological interventions, which can expand, not replace, existing care to optimize health care treatment
These are designed interventions that use medical data and clinical literature to systematically identify clinically relevant and economically significant drug-related problems, and proactively trigger specific clinical assessments, defined interventions, specified follow-up, and outcomes documentation:
Proactive identification of drug-related problems
Patient education materials are utilized to provide patients with tools to maximize medication management, and materials to enhance their level of self-carez'
Empowering patients with self-knowledge:
Effective therapeutic management is achieved using programs designed to collect patient information and drug intervention data; this allows for objective benchmarking and outcomes documentationz'
Organizing therapeutic approaches
Limitations of Disease Management Programs
It may be particularly difficult to create the relational databases needed for disease modeling within some health systems.

there may be competing disease management groups within health plans

There may be questions about long-term equity for DM companies. Once a DM company has utilized intensive efforts to shift prescribing behavior, an MCO may decide not to renew its DM contract and attempt to continue the "maintenance" interventions on its own.

relates to the number of different capitated arrangements that exist between MCOs and different hospitals and provider groups. It becomes quite difficult to quantify specific cost savings when multiple provider groups receive a specified amount of funds from MCOs regardless of service provided. Thus, a DM program may reduce the number of repeat physician visits, but there is no savings to the MCO, simply because the physician groups are capitated.