Case Management Practice Settings and Throughput
Hussein A. Tahan
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be able to:
Identify the various health care settings that constitute the continuum of care.
Define the continuum of care.
List the practice settings of case management.
Describe the role of the case manager in relation to the continuum of care and practice settings.
Define what throughput is and describe its relationship with case management.
Describe the role of the case manager in throughput and patient flow.
IMPORTANT TERMS AND CONCEPTS
Beyond-the-Walls Case Management
Continuum of Care
Independent Case Management
Input
Level of Care
Outcome
Output
Patient Flow
Payer-Based Case Management
Practice Setting
Private Case Management
Process
Structure
Telephonic Case Management
Throughput
Transition of Care
Within-the-Walls Case Management
▪ INTRODUCTION
A. Case management has been applied as a strategy or a model for care delivery in every setting of the health care continuum.
B. There are many reasons for the implementation of case management models in various care settings. Some of these are the following:
Rising number of the elderly, especially those with chronic and complex health conditions.
Use of innovative and sophisticated health care technology that tends to be costly, including biomedical informatics.
Increase in the use of minimally invasive and robotic surgery and the likelihood of performing surgical procedures in the ambulatory care setting.
Rising number of newer and rare diseases especially those that are infectious in nature and that require costly health care resources.
Popularity of life-prolonging treatments such as organ transplantation.
Changes in health care reimbursement methods, particularly those that place the provider of care or the consumer at higher financial risk. For example, managed care, capitation, and prospective payment systems.
Prospective payment systems being applied by federal and state governments reaching almost all settings of care delivery such as long-term care, home care, acute care, rehabilitation, and skilled care environments.
Educated consumers of health care.
Pressures to cut the forever rising cost of health care services.
Shortages in health care workforces including nursing; pharmacy; and physical, occupational, and respiratory therapy.
Rising ethical concerns and legal liability resulting in the practice of defensive medicine.
Shift of health care delivery and services from the acute to the non-acute care settings such as home care, long-term care, and rehabilitation care settings.
Increased demand for quality of care that is supported or evidenced by measurable outcomes.
Changes in the standards of accreditation and regulatory agencies, particularly those that impact on case management practice such as those that address continuity of care, care across the continuum, discharge planning, safety, and patients’ rights.
C. Case management is not a new approach to managing patient care. It has reached every health care setting across the continuum (Cesta and Tahan, 2003).
1880s: Outpatient and community settings, particularly the care of the poor
1920: Outpatient and community care settings, particularly the care of psychiatric patients and individuals with chronic and long-term illnesses
1930: Public health/community care settings
1950: Behavioral health across the continuum of care
1970s and 1980s: Long-term care settings through demonstration projects funded by Medicare and Medicaid waivers
1985: Acute care settings, particularly as nursing case management programs
1990s: Virtually all health care settings including managed care organizations
D. The use of case management varies from one practice setting to another, with its identifying characteristics dependent on the discipline that applies it, the professional who assumes the role of the case manager, the staffing mix, and the context of the setting where it is implemented including its related reimbursement method(s).
E. The main characteristics of case management, regardless of care or practice setting, include the following:
Outcomes-oriented care delivery that focuses on monitoring and measurement of patient safety, continuity, and quality of care
Appropriate resource allocation and utilization that is justified by the patient’s condition and the required treatment, with cost effectiveness as the ultimate outcome
Comprehensive care planning including early assessment, intervention, and linking patients and their families to needed services
Integration and coordination of care delivery to eliminate fragmentation and/or wastes
Collaboration across care providers and care settings
Advocacy to ensure that needed services are obtained and expected outcomes are met
Use of a licensed professional as the case manager
Compliance with the standards of accreditation and regulatory agencies
Open lines of communication and sharing of important information across care providers, care settings, and the patient/family
Consumer and staff satisfaction
F. Case management allows the integration and coordination of health care services across consumers of health care, providers of care, payers for services, and care settings; that is, across persons, space, and time. This is most effective because case management:
Opens lines of communication about needed and important information among providers, consumers, and payers
Facilitates an environment of collaboration among providers, consumers, and payers. Such is most evident in the presence of shared goals, effective communication, and shared decision making
Promotes a patient-centered approach to care by meeting all the patient’s and family’s needs and interests
Ensures continuity of care over time and across care settings or providers
G. Case management gained more momentum when the health care delivery system began to gradually shift away from the inpatient care setting (hospital). Owing to numerous technological advances in diagnostics, medications, and procedures, and the evolution of reimbursement plans that limit inpatient hospital stays (e.g., Medicare’s prospective payment system, and managed care health plans), most health care needs can be handled on an outpatient basis.
H. Case management has been described as “within the walls” and “beyond the walls” (Cohen and Cesta, 2005).
Within-the-walls—Case management models in the acute care/hospital settings
Beyond-the-walls—Case management models in the outpatient, community, long-term, and payer-based settings
I. Case management has also been implemented as a core strategy of population-based disease management programs.
J. Recently, case management became an essential strategy for ensuring patient safety, especially in reducing or preventing the risk for medical errors during transitions of care (handoffs), patient flow through the system of health care services, and throughput.
▪ KEY DEFINITIONS
A. Beyond-the-walls case management—Models of case management that are implemented outside the acute care/hospital setting; that is in the community, outpatient, long-term, and payer settings.
B. Boarding—Occurs as a result of situations when a patient remains in an area such as the emergency department (ED) or post-anesthesia care unit for a period of time, usually 2 hours or longer, after a decision has been made to admit the patient to an inpatient bed.
C. Crowding—Increased number of patients who are awaiting care or are in the process of receiving care in an area (i.e., care setting such as the ED) beyond the capacity the area can handle. An example is ED crowding as a result of inability to move patients out of the ED and into inpatient beds when these patients must be admitted rather than released.
D. Diversion—Occurs when hospitals request that ambulances bypass their EDs and transport patients to other health care facilities who otherwise would have been cared for at these EDs. This event happens as a result of ED crowding and situations where EDs cannot safely handle additional ambulance patients.
E. Handoff—The act of transferring the care of a patient from one provider to another, from one care setting to another, or from one level of care to another.
F. Health care continuum—Care settings that vary across a continuum based on levels of care that are also characterized by complexity and intensity of resources and services.
G. Input—Elements or characteristics taken into consideration when providing care to a patient. It also may mean the patient’s condition at the time he or she presents for care in a particular care setting such as a clinic, emergency department, or hospital. Examples may include age, gender, health status, social network, reason for accessing health care services, or insurance status.
H. Left before a medical evaluation—Occurs when a patient who presents to the ED for care, but leaves the ED after triage and before receiving a medical evaluation. Generally this happens with nonemergent conditions where patients need to wait for treatment.
I. Level of care—The intensity of resources and services required to diagnose, treat, preserve, or maintain an individual’s physical and/or emotional health and functioning. Levels of care vary across a continuum of least to most complex resources and/or services—that is, from non-acute, to sub-acute, to acute, to critical.
J. Level of service—The delivery of services and use of resources that are dependent on the patient’s condition and the needed level of care. Assessment of the level of service is used to ensure that the patient is receiving care at the appropriate level.
K. Outcome—The result, output, or consequence of a health care process. It may be the result of care received or not received. It also represents the cumulative effects of one or more processes on an individual at a defined point in time. Outcome can also mean the goal or objective of the care rendered.
L. Output—Results or outcomes of care provision. It also may mean the patient’s condition at the time he or she exits a health care setting or transitions to another level of care or location. Examples may include death, discharge to home with home care or no services, or discharge to a skilled nursing facility.
M. Patient flow—The movement of patients through a set of locations in a health care facility. These locations are the levels of care required by the patient based on health condition and clinical treatment. Patient flow entails the transitioning of an individual from point A to point B of a health care facility or setting; that is, from the patient’s entry point to the checkout point of the health care facility where care is being provided.
N. Practice setting—A care setting in which a case manager is employed and is able to execute his or her responsibilities. Care settings vary across homogeneous populations of patients such as organ transplant, pediatrics, and geriatric; or across physical care delivery areas such as
ambulatory/clinics, acute/hospital, long-term, skilled care facilities, or sub-acute rehabilitation.
ambulatory/clinics, acute/hospital, long-term, skilled care facilities, or sub-acute rehabilitation.
O. Process—The methods, procedures, styles, and techniques rendered in the delivery of health care services. These relate to the roles, responsibilities, and functions of the various health care providers and how they go about fulfilling them.
P. Structure—The characteristics of the system/environment of care or health care organization including those associated with the providers of care and the patients/families who are the recipients of care. It relates to the level of care or setting; the nature of the care delivery model; the health status of the patients; and the skills, knowledge, education, and competencies of the health care providers.
Q. Throughput—The actual operations of a care setting. It also refers to the clinical and administrative processes applied in the setting to deliver quality patient care and services. Processes may include the use of a case manager; availability of ancillary services such as pharmacy, laboratory, and radiology; and the type of treatments implemented for the care of a patient.
R. Transition of care—The process of moving patients from one level of care to another, usually from most to least complex; however, depending on the patient’s health condition and needed treatments, the transition can occur from least to most complex.
S. Within-the-walls case management—Models of case management that are implemented in the acute care/hospital-based setting.
▪ CASE MANAGEMENT PRACTICE SETTINGS
A. Case management is practiced across all settings of the health care continuum in varying degrees of complexity and intensity and is dependent on the following four factors:
The context of the care setting (e.g., ambulatory versus acute/hospital);
The patient’s health condition and needs (e.g., critical/acute episode of illness versus long-term and chronic condition);
The reimbursement method applied (e.g., managed care or capitation versus prospective payment system); and
The type of care provider(s) needed for care provision (e.g., generalist versus specialist physician, individual provider versus a multidisciplinary team).
B. The role of the case manager also varies based on the care/practice setting and the above four factors. It tends to be more complex as the needs and services a patient requires intensify. The role also is more necessary and valuable when a multidisciplinary team of providers is involved in the care of a patient compared to a single or primary care provider alone.
C. The best and most effective models of case management are those that focus on the continuum of care and settings. Regardless of the setting in
which the model is implemented, it is most beneficial if it facilitates (specifically in the role of the case manager) open lines of communication and collaborations/partnerships with health care providers practicing in other settings, emphasizes a patient- and family-centered approach to care provision, and ensures that the patient/family needs are addressed even beyond the setting the patient accesses for care.
which the model is implemented, it is most beneficial if it facilitates (specifically in the role of the case manager) open lines of communication and collaborations/partnerships with health care providers practicing in other settings, emphasizes a patient- and family-centered approach to care provision, and ensures that the patient/family needs are addressed even beyond the setting the patient accesses for care.
D. According to Cesta and Tahan (2003), the health care continuum can be divided into three major settings based on the scope, type, and cost of services provided. These are:
Pre-acute setting
Focus is on the prevention of illness or deterioration in an individual’s health condition
Least complex services; primarily proactive approach to care provision that can be self-directed or that may not require the attention of a health care provider
Cost is low; in some instances may be free
Examples may include primary prevention of illness in the form of health promotion, risk assessment, and screening; fitness; counseling; lifestyle changes; and behavior modification
Provision of care does not require admission to a health care facility; care may be limited to a clinic or outpatient setting including a physician’s office, a managed care organization, and community-based health centers
Case management services are minimal and include telephonic health promotion services and advice lines, health appraisals, and risk-reduction strategies
Acute setting
Focus is on treating an acute episode of illness such as medical or surgical management, and trauma or emergency care
Most complex services; primarily reactive approach to care provision and requires the attention of a health care provider(s)
Cost is high; care provision may require the authorization of the payer or insurer
Examples may include secondary and tertiary prevention of illness, major diagnostic and therapeutic modalities, surgical/operative procedures, medical management, acute or intensive/critical care, emergency care, specialty care
Provision of care requires admission to an acute care facility/hospital, acute rehabilitation facility, post-anesthesia and intensive care area, or emergency department
Case management services are intensive and comprehensive in nature including primarily care coordination and management
Post-acute setting
Focus is on the provision of services needed by patients after an acute episode of illness that may have required an acute care/hospital admission
Moderate complexity services; primarily reactive approach to care provision and requires the attention of multiple health care professionals such as physical and occupational therapists
Cost is moderate to high; care provision may require the authorization of the payer or insurer
Examples may include home care, palliative and end-of-life care, rehabilitative and restorative services, long-term care including custodial and skilled care
Provision of care may occur in the home or community setting or may require admission to a health care facility such as a sub-acute rehabilitation or nursing home, assisted living, hospice, day care centers
Case management services are moderate to complex including primarily transitional planning activities such as placement of patients in appropriate level of care/setting
E. The pre-acute case management practice settings include:
Telephonic
Payer-based or managed care organization
Ambulatory or clinic/outpatient
Community care
Disease management (see Chapter 20)
F. The acute case management practice settings include:
Hospital (see Chapter 4)
Acute rehabilitation (see Chapter 6)
Emergency department
Transitional hospitals, also known as sub-acute care facilities (see Chapter 6)
Disease management (see Chapter 20)
G. The post-acute case management practice settings include:
Sub-acute (see Chapter 6)
Home care (see Chapter 5)
Long-term care (see Chapter 6)
Palliative or hospice (see Chapter 7)
Respite care (see Chapter 6)
Residential (see Chapter 6)
Custodial (see Chapter 6)
Assisted living (see Chapter 6)
Day care (see Chapter 6)
Independent or private case management agency
Workers’ compensation (see Chapter 18)
Disability management (see Chapter 19)
Occupational health (see Chapter 19)
Life care planning (see Chapter 17)
Disease management (see Chapter 20)
▪ TELEPHONIC CASE MANAGEMENT
A. Telephonic case management is defined as the delivery of health care services to patients and their families or caregivers over the telephone or via the use of various forms of telecommunication methods such as fax, e-mail, or other forms of electronic communication methods.
B. Most commonly used in the managed care organization (MCO) setting. It takes place in the form of communication between the MCO representatives (mostly MCO-based case managers) and its members.
C. Became more popular in the 1990s with the increased infiltration of managed care health plans. It was viewed as an essential strategy for cost containment.
D. MCOs provide telephonic case management services as an additional benefit to their members. Through this strategy telephonic triage and the provision of health advice have become more common. Through these approaches, case managers ensure the appropriate use of health care resources and allocated such resources based on the needs of the individual member.
E. Telephonic case management is considered a cost-effective and proactive approach to preventing catastrophic health outcomes or deterioration in a patient’s condition that requires acute care or a hospital stay.
F. Case managers provide telephonic case management services on a 24 hours/7 days-a-week basis. The main focus is triage services and utilization management of health care resources.
G. Case managers in the telephonic case management practice setting engage in the following activities:
Telephonic triage
Easing the access of patients to health care services
Facilitating the access of the patient to the appropriate level of care, health care provider, and service
Intervening in a timely manner and sharing real time information
Empowering the patient/family/caregiver to assume responsibility for self-care and health management
Identifying the patient’s health risk and instituting appropriate action or referral for services
Engaging in cost-reduction activities by promoting access to health services that are appropriate to the patient’s condition; for example, preventing the provision of care in the emergency department setting when the patient’s condition does not warrant such services, rather directing the patient to seek health services by the primary care provider
Educating patients and their families about health regimen and encouraging them to adhere to it
Following up with patients and/or their families post-discharge from a hospital or ED to ensure safety and adherence to medical regimen, answer their questions, and provide counseling and emotional support
Coordinating and integrating services using evidence-based algorithms, protocols, or guidelines, which include decision trees that are based on certain criteria or assessment cues/data
Assessing and evaluating the patient’s condition over the telephone; identifying problems; and directing appropriate action. The assessment is guided by the relevant protocol, and depending on the findings, the case manager determines the urgency of the situation and decides on the necessary type of intervention or advice
Counseling patients regarding their health benefits and answering their questions
Providing health advice
Explaining claims
Authorizing services
Brokering services or directing other case managers to arrange for community-based services with participating agencies or providers
H. Case managers in the telephonic case management practice setting also apply the case management process, however, without a face-to-face interaction with the patient or family. In this process, they:
Interview the patient and/or family member/caregiver
Complete an assessment or evaluation of the patient’s condition, situation, or the reason for the call
Analyze the findings using an algorithm or a guideline (usually automated)
Determine the urgency of the situation and plan care (i.e., triage or advice) accordingly
Implement necessary action or care strategy (e.g., refer to ED or the primary care provider)
Evaluate outcomes
Document episode of service
I. Telephonic case management is known to apply two main strategies to ensure cost effectiveness and the provision of care in the most appropriate setting and by the necessary care provider. These are:
Demand management
The main focus is on the appropriate utilization of resources and services
Case managers provide patients with information about their disease, disease process, medical regimen, and desired outcomes
Case managers also encourage patients to participate in self-care and in making decisions regarding their health care needs
The primary outcome is reduction in unnecessary use of EDs, urgent care settings, or acute care facilities
Telephone triage
The main focus is sorting out requests for services based on severity, urgency, and complexity
J. In deciding on the urgency of need for access to health care services, case managers place patients into three categories based on the findings of the telephonic assessment and evaluation. These are:
Emergent
Need to be seen by a health care provider immediately (e.g., acute chest pain)
Usually the patient is referred to the ED
May need the help of emergency medical services personnel
Urgent
Need to be seen within 8 to 24 hours (e.g., vomiting)
Usually the patient is referred to the primary care provider
Health advice may be given to be followed while the patient is waiting to see the primary care provider (e.g., drink extra fluids)
Nonurgent
Can be seen routinely by a primary care provider or treated at home with appropriate follow up (e.g., minor bruise or abrasion)
Health advice is given and the patient is directed to see the primary care provider within a certain number of days if symptoms are not improved
K. In making triage decisions, case managers also use other information such as age, gender, past medical history, medications intake, and primary care provider. In addition, they may ask for health plan-related information such as plan/account number, location of residence, and so on.
L. A rule of thumb for the case manager in telephonic triage is referring those who require care to the appropriate care provider and optimal setting.
▪ CASE MANAGEMENT IN THE PAYER-BASED SETTING OR INSURANCE COMPANIES
A. Case managers in the payer-based setting are employees of the insurance company (i.e., health maintenance and managed care organizations.
B. In this setting, the main focus of case management is the health and wellness of the enrollee and the role of the case manager as a liaison between the providers of care—whether an individual or an agency/facility—and the insurance company.
C. Case managers are not the “claims police” despite the fact that they ensure cost-effective treatment plans. Rather, they are:
Coordinators of care, problem solvers, advocates, and educators;
Professionals who collaborate with physicians and other care providers (including the provider-based case manager) to ensure the provision of appropriate and safe care;
Negotiators of services such as home care, durable medical equipment, and physical therapy;
Counselors in that they ensure that the patient follows the prescribed treatment plan; and
Liaisons with insurance claims staff. In this regard, they clarify insurance claims information (Mullahy, 2001).
D. In the payer-based setting, case managers build programs or systems that make it feasible to identify enrollees who are at risk for illness, and those who are considered the “high-risk, high-cost” cases.
Examples of such cases are: cancer, AIDS, organ transplantation, head/brain injury, spinal cord injury, severe burns, high-risk pregnancy, neuromuscular problems, and others.
Case managers work closely with these types of enrollees to ensure they receive the services they need in the appropriate level of care/setting and by the necessary provider(s).
The main goal is provision of quality and cost-effective care.
E. Mullahy (2001) also identified four major areas of activities for case managers in the insurance/managed care practice setting. Some of these activities are applied based on the need and the situation or the job description designed by the insurance company. The areas of activities are described below.
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