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Guide to Patient-Centered Case Management - Revised 2011 Edition
Healthcare Intelligence Network, August 2011, Pages: 118
Healthcare case managers are taking on more responsibility in the care coordination continuum — from management of the chronically ill in primary care to overseeing post-acute transitions in care to educating patients on appropriate use of the emergency department. Market research by the Healthcare Intelligence Network indicates that 85 percent of healthcare organizations are using case managers, with many companies co-locating case managers alongside healthcare providers.
The 118-page Guide to Patient-Centered Case Management, Revised Edition, presents best practices in identifying, stratifying and monitoring individuals for case management and documents the returns generated by targeted case management interventions in place at Geisinger Health System, Aetna Medicare, Priority Health and other organizations. This resource contains 70 illustrative figures and its Q&A chapter answers more than 50 questions on patient-centered case management.
Don't wait to order your organization's copy of Guide to Patient-Centered Case Management, Revised Edition, and begin to apply these case management interventions to your high-risk, high-utilization populations.
Executive Editor’s Note
Chapter 1: Overview
2011 Case Management Survey Highlights
Key Findings
About the Survey
Respondent Demographics
Conclusion
Chapter 2: Long-Term Complex Case Management
Team-Based Case Management Programs
Using Predictive Models to Identify High-Risk Populations
Four Conditions Used to Classify Members
Using Questionnaires to Determine Care Plans
Five Domains of Patient Assessment for Case Selection
Effective Staffing of Case Management Teams
Monitoring Case Manager Performance
Calculating Program ROI
Chapter 3: Best Practices in Care Coordination
Key Elements of Care Coordination
Goals of Care Coordination
Focus on Care Transitions
Heart Failure Care Coordination
Diabetes Care Coordination
Chapter 4: The Embedded Case Manager
Geisinger’s Medical Home Model
The Embedded Case Manager
Selecting a Case Manager
Case Manager Skill Sets and Key Qualities
Case Manager Training and Support
Identifying Target Populations for Case Management
Post-Discharge Case Management
Case Management in Home Health, SNFs and Care Transitions
Success from the Case Manager Effort
Chapter 5: Assessing Health Risk in the Elderly
Measuring Risk Factors
Coordinating with Physicians to Reduce Readmissions
Tools to Reduce Costly Risk
Risk Adjustment and Reimbursement
HRAs to Identify Risk
Chapter 6: Case Management to Reduce Readmissions
The IHI Triple Aim Model
Pilot for Population with Cardiovascular Conditions
In-Hospital Process Heads off Readmissions
Outpatient Case Management
Value of Follow-Up Visit
The Post-Discharge ‘Handshake’
Outcomes of Cardiovascular Initiative
Expanding the Care Transitions Intervention
A Priority Health Success Story
Hope from the Patient-Centered Medical Home
Chapter 7: Q&A: Ask the Experts
Explaining Case Management to Members
Evaluating Program ROI
Staffing Case Management Programs
Case Manager Case Load
Transitioning Between Outreach Teams and Case Management
Embedding Teams in Primary Care Practices
Compiling an Outreach Effort Spreadsheet
Staffing a Transitional Team
Optimum Patient Management
Adult Day Services
Patient Costs
Case Manager Skill Sets
Role of Home Health
Nurse-to-PCP Ratios
Medication Reconciliation
Patient Monitoring
Patient’s Plan of Care
Advanced Illness Program
Support Staff Requirements
Fitting Case Management Into the Medical Home
Engaging Non-Compliant Patients
What is a Complex Case?
Integrating the Medical Home with the Health Plan
Technology Supporting the Medical Home Model
Staffing the Case Manager Call Center
Home Health and Home Visits
Stratifying Complex Patients
Case Manager Competencies
Investment in Medical Home Infrastructure
Targeted Case Management Populations
The Case Manager’s Role in the Practice
Engaging the Practice in the Program
Making the Most of the Case Manager Resource
Case-Managing the Sick of the Sickest
Building Physician Buy-In for the Embedded Case Manager
Case Management Tools
Predictive Modeling for Risk Identification
Funding and Reimbursement for the Embedded Case Manager
CCM Certification
Time Line for Program Implementation
Importance of Technology in Program Model
Using Screening Tools to Indicate Risk
Predictable Factors in Medical Cost Control
Role of the Community Pharmacist
Medication Reconciliation
Tracking and Measuring Health Risk
Physician and Case Manager Collaboration
Role of the Case Manager
Online HRAs
Using HRA to Prevent Hospital-Acquired Infections
Predicting Risk During Care Transitions
Stratifying High-Risk Factors
The Caregiver’s Role in Assessing Risk
Demographic, Income and Geographic Factors
Sharing a Member’s Risk Score
Determining a High-Risk Patient
Unintended Consequences from Care Transition Efforts
Follow-Up Protocols for Heart Failure Patients
Red Flag Education Tools
Hospitals’ Response to Reimbursement for Quality
Funding for Care Transitions
Glossary
About the Authors
List of Figures
Figure 1: Case Manager Work Locations
Figure 2: Care Support Team Members
Figure 3: Care Support Program Structure
Figure 4: ACG-PM Risk Scores
Figure 5: Opportunity for Impact
Figure 6: Targeted Stratification Methods
Figure 7: Previous View of Condition Prevalence
Figure 9: Combining Condition Markers and Utilization
Figure 8: Risk Scores for Four Key Conditions
Figure 10: Stratifying Members for Care Management
Figure 11: Care Management Competencies
Figure 12: Sample Case Manager Interview Questions
Figure 13: Measuring Proficiency with Motivational Interviewing
Figure 14: Patient Activation Level at Baseline
Figure 15: PAM Trend — Activation Score
Figure 16: Sample Care Manager Care Plan
Figure 17: Evaluating Cost Per Capita
Figure 18: More ROI Data
Figure 19: Joining Care Coordination & Disease Management
Figure 20: Successful Tactics for Care Coordination
Figure 21: Sutter Care Coordination Program
Figure 22: Sample Guideline-Based Care Plan
Figure 23: Benefits/Focus of Care Coordination Program
Figure 24: SCCP Utilization Measures — Cost
Figure 25: SCCP Utilization Measures — Visits
Figure 26: Heart Failure Management Interventions
Figure 27: Heart Failure Monitoring Guide
Figure 28: Heart Failure ACE/ARB Rates
Figure 29: Diabetes Management Interventions
Figure 30: Risk Stratification for Diabetes Monitoring
Figure 31: Monitoring Guidelines from Labs
Figure 32: Improvements in Diabetes Compliance
Figure 33: Geisinger’s Integrated Health Service Organization
Figure 34: Five Core Components of the ProvenHealth Navigator Model
Figure 35: Health Navigator Quality Criteria
Figure 36: Clear Opportunity Lies with Inpatient Admissions
Figure 37: Clear Opportunity Lies with Readmissions
Figure 38: Embedded Case Managers Keys to Success
Figure 39: Case Manager Nursing Backgrounds
Figure 40: Key Qualities of a Case Manager
Figure 41: Skill Sets of a Case Manager
Figure 42: Training Case Managers
Figure 43: First Steps for High-Risk Case Identification
Figure 44: MEDai: Risk Navigator Clinical
Figure 45: Population Identification
Figure 46: Post-Hospital Management
Figure 47: Sample HF Self-Management Action Plan
Figure 48: Telemonitoring Tools
Figure 49: Disease Management at Geisinger
Figure 50: Vertical Build of Case Management
Figure 51: SNFs — Opportunities to Partner
Figure 52: Best Practice Shows More Dramatic Improvements Possible
Figure 53: High-Risk Member Resource Consumption
Figure 54: Quality-Based Medical Management Approach to Identified Risk
Figure 55: Identifying and Stratifying Impactable Medical Risk
Figure 56: Hospital Admissions and Readmissions
Figure 57: Measuring Readmissions: Absolute Rate vs. Percentage
Figure 58: Aetna-Intel Medicare Biomonitoring Study
Figure 59: Collaborative Care Management
Figure 60: Biomonitoring Study
Figure 61: Medicare Adjusted Risk Scores
Figure 62: Specific Coding Can Make a Big Difference
Figure 63: Example of Hospital Chart
Figure 64: Less Effective HRA Approaches
Figure 65: Priority Health In-Hospital Intervention
Figure 66: Priority Health Post-Discharge and Home Care
Figure 67: Case Management from Hospital to Home
Figure 68: Care Transitions: Outcomes 2008
Figure 69: Comparing Medicare FFS and Medicare Advantage Utilization
Figure 70: Care Transitions Expansion for Heart Failure Registry
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