Case Management

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he number of staffed beds

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is a measure of the size and complexity of acute care hospitals

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The number of hospital clinical services

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s measured by the sum of all the services provided by the hospital as listed in the AHA survey and is an indicator of organizational complexity. Because a broad range of clinical services increases market potential, the number of clinical services has a positive correlation with hospital performance

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Age of physical plant

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is defined as accumulated depreciation divided by depreciation expense (Levitz & Brooke, 1985). The age of physical plant is a measure of the physical stature of the hospital with a modern facility representing higher quality of clinical care. It is also an indicator of an organization's capital needs, with higher values indicating an older facility.

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Capitated lives

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represent the number of patients enrolled in capitated contracts for each individual hospital as reported in the 2001 AHA Annual Hospital Survey. These capitated patients represent at-risk reimbursement arrangements in which the hospital receives a pre-arranged fixed payment and, in turn, guarantees care to the capitated patients. The number of capitated lives is directly correlated to the amount of positive revenue the hospital is able to acquire

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Operating performance

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s measured at the individual hospital level and includes the following variables: return on assets (ROA), occupancy rate, and operating expense per discharge

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A negative ROA

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s an indicator of poor financial performance and potential facility closure. According to Harrison et al. (2003), occupancy rates have dropped to 50% nationally. Hospitals with low occupancy rates are at greater risk for acquisition and potential closure.

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operating expense per discharge

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is a measure of organizational efficiency and is a key factor of hospital performance.

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Hospital occupancy

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is defined as the total number of inpatient days divided by the beds in service. Occupancy has dropped as care shifts away from inpatient acute care to outpatient services, with less than 50% of all beds in operation occupied (Yafchak, 2000). Hospitals with high occupancy rates indicate a strong market demand for services and increase the likelihood of hospital profitability. Hospitals with occupancy rates lower than the national average have an increased likelihood of acquisition or closure

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the market variables

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represent the demand for the hospital's services and include per capita income, percent of the population over 65, unemployment rate, and HMO penetration. Since the market is external to the hospital, it is measured at the county level. The use of county data to measure hospital markets has been used extensively in hospital research

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High per capita income

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reflects a sound economic community where individuals hold well-paying jobs. This is expected to increase demand for hospital services and have a positive effect on hospital profitability. Improved profitability is caused by greater health insurance coverage, an increased ability to pay for care, and reduced indigent care. Thus, higher income per capita should reduce environmental uncertainty and lower the rate of acquisition or hospital closure

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Hospitals with case management programs tend to

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have highter per capital income, less elderly pts, had higher return on assets, higher occupancy rates, and lower operating expenses per discharge.hospitals with a case management program were larger, had more clinical services, and had more enrolled capitated lives.

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case management programs

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ecrease use of intensive services, shorten length of stay, and decrease readmission rates for populations with chronic illnesses such as COPD and cardiac disease- however if there is a large elderly population this is a negative coefficient -positive is HMO penetration

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high managed care penetration

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eads to fewer hospital admissions and shorter length of stay.

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ROA

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Return on Assets
hospitals with case management programs are more efficient and have higher profitability. Of even greater interest in this study is that hospitals with case management programs have a positive mean ROA of 2.8%, while hospitals without a case management program have a negative mean ROA of 0.46%

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Coordination of care across multiple clinical disciplines

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provides better patient care and eliminates costly duplication of services, thus meeting needed efficiency and quality outcomes

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In case management programs the nurse's role

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is one of manager or coordinator of services who influences patient advocacy and resource control

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ALOS

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average length of stay

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hospital case management

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a key driver of managing access to care, effective coordination of care processes, quality outcomes, and, in the end, human and financial resources. Case management involves an approach and an organizational attitude to achieving these ends, not simply a team of nurses and social workers with the job title "case manager."

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PA

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physician advisor
oversee quality and utilization management issues related to physician practice. PAs serve as resources to case managers who are dealing with specific patient situations. Through weekly meetings and daily conversations, PAs can intervene with peers in difficult cases. Ideally, PAs are involved in cases within their specialty. Traditionally, hospitals have a utilization management committee that meets monthly to review data or historical cases.

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The case manager and bedside nurse

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create a daily routine of conveying key aspects of the patient's severity of illness, intensity of service, plan for care, and other social influences that may effect progress and discharge

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Assignment by unit

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s most common, particularly in mid to large-sized hospitals because patient units typically care for patients with like diagnoses. The advantages of this model include additional work efficiency due to geographic proximity, but more importantly, the benefit of establishing solid working relationships with the nursing and ancillary staff working on the unit.

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assigning patients by diagnosis

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enable the case manager to develop expertise in the diagnosis, treatment, and expected outcomes of particular diseases and conditions. This expertise enables the case manager to provide more valuable information to patients in order to support their decision making and manage their expectations of their hospital and post-acute care experiences. This expertise also supports the credibility of the case manager with physicians.

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patients are assigned according to attending physician

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This approach emphasizes physician communication and relationships through a partnership and service orientation. In organizations where a traditional utilization management and discharge planning approach has been used, the relationships between these staff and physicians can be characterized as adversarial. Physicians often feel hassled rather than helped by the "nagging UR witch." A physician-centric case management model can help an organization effectively transition into a more contemporary approach for managing care by approaching physicians with a mentality emphasizing personal service. When performed effectively, physicians find this approach invaluable. Once a more constructive and cooperative relationship is establish, true partnerships can evolve that reflect the unique and indispensable roles of the physician and case manager.

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Assignment by payer type

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used successfully in organizations with unique payer issues such as payers with intricate reimbursement mechanisms like capitated managed care contracts including carve-out patient populations or burdensome utilization management requirements like worker compensation. Another example includes institutions with a high percentage of patients with pending Medicaid coverage.

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used successfully in organizations with unique payer issues such as payers with intricate reimbursement mechanisms like capitated managed care contracts including carve-out patient populations or burdensome utilization management requirements like worker compensation. Another example includes institutions with a high percentage of patients with pending Medicaid coverage.

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addresses "six essential activities of case management: assessment, coordination, planning, monitoring, implementation, and evaluation in multiple environments." These "environments" include "process and relationships, health care management, community resources and support, service delivery, psychosocial intervention, and rehabilitation case management."

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Job Performance

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First, the case manager must review every case every day. The process of case review involves a combination of examining the medical record and seeking out new test results. Conducting some form of interactive rounds with the nursing staff and other relevant clinical disciplines should occur daily. These routines enable the practice of day one discharge planning.

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Job Performance

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Routine communication with physicians is critical to building partnerships. Case managers should avoid leaving notes on the chart reminiscent of "UR Love Letters." Ideally, the case managers know the routines of the majority of the physicians responsible for their patients and make themselves available when physicians round on their patients. If direct contact is not feasible, the case manager should gather an updated picture of the patient's current condition and future needs. They should be prepared to provide a concise summary, key questions to anticipating future needs or resolving issues, and a set of options in anticipation of discharge

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job performance

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ase managers often serve as the eyes and ears for many areas by collecting data for utilization review, quality assurance, medical records, and risk management purposes

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LOS reports

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Most hospital information systems will provide LOS reports by diagnosis, nursing unit, and physician

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Utilization review (UR)

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is a safeguard against unnecessary and inappropriate medical care.[1] It allows health care providers to review patient care from perspectives of medical necessity, quality of care, appropriateness of decision-making, place of service, and length of hospital stay.

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UR judgments

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frequently are based on actuarial assessments of cost-benefit scenarios and/or clinical guidelines. In the former, the most common by Milliman and Robertson,[2] the guidelines clearly state that the final decision for treatment for specific individuals should be made only in conjunction with the application of professional medical judgment.

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Employee Retirement Income Security Act of 1974 (ERISA)

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was promulgated to guarantee the well-being and security of employer-sponsored benefit plans. The federal district courts have jurisdiction for any civil action under ERISA, limiting relief to the recovery of benefits due, enforcement of rights under a claim, or to clarify rights to future benefits. ERISA is designed to return to a covered participant benefits due. It is silent with respect to remedies should the participant be injured or damaged, lose wages, or become disabled as a result of the intervention in the doctor-patient relationship by any managed care entity. Congress intended that ERISA should supersede any and all state law insofar as the state laws related to "any employee benefit plan."

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Shaw v Delta Airlines, Inc.

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hat "a state law relates to an ERISA plan if it has [any] connection with or reference to such plan."[6] As a consequence of this ruling, any malpractice action brought against an ERISA plan is preempted by federal law. Preemption would remove a state court claim to federal court. The federal court would then dismiss the claim because ERISA specifically does not afford relief for a malpractice claim. It would only afford relief for reinstitution of the benefits denied. Shaw undermined the state's interest in protecting the quality of health care afforded to its citizens.

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Ciccio

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Not until this year did any federal court address the criteria on which managed health care UR decisions could be evaluated to determine patient-specific prescription of appropriate treatment that rises to medical decision making
n removal to federal court, the Second Circuit Court of Appeals observed that the correspondence between the treating physician and the utilization review of the managed care company strongly suggested that the insurance company was engaged in medical decision-making. The court based this conclusion on the following facts:

The treating physician supplied a thorough case history.
UR made medical determination on the basis of an aggregate of symptoms.
The treating physician appealed the UR denial.
The UR denial was "based on clinical peer review of additional information."
The court concluded that by denying one treatment and authorizing another, UR is engaged in patient-specific prescription of an appropriate treatment. This action amounts to medical decision-making. The court held that decision-mak-ing that affects the quality of medical care is a state law claim and not preempted by ERISA.
hould the UR still deny care on the basis of patient-specific reasoning, then the patient may have recourse against the UR based on a state law claim of malpractice. Furthermore, state legislatures, through the lobbying efforts of its citizens, have the right to monitor and enforce standards for reasonable medical care to protect the health and welfare of its citizens, even when that effort impinges on ERISA-covered managed health care plans.