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Changing Your Case Management Care Model

Case management department key to providing balance between quality patient care and reimbursement.

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Learning Scope #416
1 contact hour
Expires Jan. 14, 2015

You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this continuing education offering is to provide the latest information to nurses about case management. After reading this article, you will be able to:

1. Describe the compliance and regulatory knowledge of Medicare and Medicaid programs that impact case management.

2. Identify the difference between the dyad and triad models for case management.

3. Demonstrate the use of data to develop a workflow tool that will determine the skill mix and outcomes needed to meet future needs of your case management department.

  • The author has completed a disclosure form and reports no relationships relevant to the content of this article.

With limited resources and many challenges facing healthcare today, the case management department is key to providing the balance between quality patient care and reimbursement. Many hospitals face financial pressures placed on them from the Centers for Medicare & Medicaid Services (CMS) with the implementation of the recovery audit contractors review, denials of hospital admissions and the value-based purchasing program that includes financial penalties for readmissions.

Having the right skill mix and FTEs to manage specific patient populations for either complex medical issues or psychosocial concerns is imperative to providing care coordination, maintaining length of stay (LOS) and preventing readmissions and denials.

Additional new federal regulations that have become the responsibility of the case management department to implement, in collaboration with the patient's primary care provider (PCP), include the distribution of Medicare's Important Message, the Medical Orders for Life-Sustaining Treatment (MOLST) and the new face-to-face form which provides physician orders for home health service.

Two Models of Care

Baltimore's MedStar Franklin Square Medical Center is a 380-bed acute and subacute community teaching hospital with the busiest emergency department in Maryland. Many days start off with our patients being held in our ED waiting for discharges on the inpatient side so they can be moved upstairs. The case managers and social workers have to prioritize their work based on known discharges to allow our ED to function at full capacity and avoid the need for patients to be diverted from our hospital.

Three years ago, our case management model of care was unit based using the dyad model of care. All the care coordination, discharge planning and utilization review (UR) was done by a nurse case manager and social worker. They divided their responsibilities as shown in Table 1.

Under this care delivery model, the nurse case manager was so focused on completing the clinical reviews that the social worker was forced to perform most of the discharge planning functions, including the management of complex medical discharges, with little time left for psychosocial assessments and interventions. In addition, there was no concurrent management of potential denied days for lack of medical necessity to validate inappropriate admissions, continued stays or determination whether a patient was in the wrong level of care.

With the dyad model of care not delivering the outcomes needed to meet the current and future needs of our department, I developed a 12-month plan to convert from a dyad model of care to a triad team-based model of care. This gave us a better mix of case managers and social workers for a specific patient population with their focus on care coordination, discharge planning and readmissions.

The UR function was broken out to be performed independently with the focus on performing timely clinical reviews for our Medicaid HMOs and commercial payors as well as to perform 100 percent review on all Medicare patients to ensure they are in the correct admission status and level of care using InterQual and Milliman medical criteria. The triad model responsibilities are shown in Table 2.

Using LOS data, patient days, payor mix, case mix index, discharges to subacute, acute and psych facilities, home health agencies and initial assessments, three inpatient clinical teams were developed. See Table 3. Each clinical team was comprised of nurse case managers and social workers with a variation of skill mix and FTEs based on the patient populations they would be caring for.

Workflow Tools

With input from my social workers and case managers, I developed a workflow tool to document every assessment and intervention that they provided to our patients and established a level from one to four that determined the intensity of each assessment or intervention performed.

Level one, for example, indicates that the nurse case managers or social workers spent less than 15 minutes of their time to complete the intervention or assessment; level four is for interventions or assessments requiring an hour or more. See Table 4 and Table 5.

A tool also was developed for outpatient services and the ED. See Table 6.

An analysis of six months of data from the social worker and nurse case manager interventions and assessments demonstrated which nursing units had patients with heavy psychosocial needs and enabled us to achieve much-needed load balancing. With the right mix of skills and FTEs in place, we've been able to provide more focused and coordinated care.

The teams with three social workers, Team A and B, care for patients with end-of-life issues, chronic disease, substance abuse and family conflict. The team with three case managers and two social workers, Team C, has medically complex patients and represents patients that have cardiac disease, surgery or a recent transfer from our ICUs. The telemetry unit has an average of one-third of their patients being discharged each day. Each team cares for 96-105 patients.

The nurse case managers and social workers on each clinical team work in collaboration. They communicate with each other every morning to determine how they will coordinate the care of their patients that day. The nurse case managers will take the medically complex patients and the social workers will take the patients with predominate psychosocial needs. Patients that are both medically complex and have psychosocial needs will be managed together.

Each team is responsible to participate in their unit multidisciplinary rounds, orient their new team members, provide a hand off when one of them will be taking time off and to check in with each other throughout the day to see if anyone needs help. Preventing any delay in testing or procedures is imperative as many payors now are denying days in the middle and end of an admission due to any delays in care.

We always have used an electronic case management and discharge planning software product to facilitate the communication and collaboration with all of the home health agencies, sub-acute centers, durable medical supply companies and other community resources to which we make referrals.

Recently, we purchased onsite wireless telephones and messaging systems for all the case managers and social workers. This allows them to be in immediate contact with the patient's PCP, family and other members of the healthcare team throughout the day to discuss any barriers to discharges, patient needs or concerns.

Evolution of Model

In the past 10 months at MedStar Franklin Square Medical Center, patients that were Medicaid pending went from 183 to 339 and patients that were self-pay went from 706 to 781. The need to access community resources, medication assistance programs and mental health facilities became critical to prevent readmissions, maintain our LOS and coordinate a safe discharge plan.

The most significant change to our case management model of care was pulling all the UR functions and denial management away from the nurse case managers. We determined that in order to maintain a strong patient flow from admission to discharge, provide support to our ED so they can run at full capacity and prevent the diversion of patients to another hospital, we needed the case managers and social workers to focus only on care coordination and discharge planning.

We provided the UR nurses with laptops to allow them mobility out on the nursing units. They were trained to use both InterQual and Milliman medical criteria to perform their clinical reviews. Every Medicare and Medicaid patient is reviewed to determine whether the admission meets medical necessity for either an inpatient or outpatient observation and the appropriate level of care. All patients placed in observation are evaluated daily to determine if their medical condition has changed so they would now meet inpatient criteria.

For any patient placed in an inpatient status and upon initial review by the UR nurse did not meet inpatient criteria, the physician of record and the case management medical director would make a final decision about the patient's status. If the decision was to go from inpatient to outpatient observation, a Condition Code 44 would be documented in the medical record and the UR nurse would notify the billing department.

In addition, every admission is checked by a UR nurse for an accurate written physician order that includes the actual order written as admit to inpatient, place in outpatient observation or outpatient extended recovery, date, time and signature. Other responsibilities added to the UR nurse are to calculate the observation hours and submit them for billing purposes.

Prior to any surgical procedure being scheduled, the UR nurse works closely with the OR scheduler to determine if the surgical procedure scheduled as an inpatient is on the Medicare inpatient only list. The UR nurse also confirms that all surgical procedures have an authorization when appropriate.

Denial Management

On the denial management front, we need to determine that every patient requiring an admission to the hospital is placed in the correct admission status and level of care, whether they are coming through the ED, ambulatory surgery center or direct from their physician's office. In order to prevent denials and reduce the resources required to defend our appeals, we placed a nurse case manager with UR knowledge in the ED to serve as a consultant with the ED physicians to assist with the final determination if the patient should be an inpatient or outpatient observation admission.

For many hospitals, the case management department also is responsible to deliver observation letters to their patients and families that will provide them with an understanding of their financial responsibilities.

When the RAC and MAC began to request medical records for one-day inpatient stays for medical necessity and to determine if the care could have been delivered in a lower level of care, it became apparent we needed to establish a process that would prevent any additional risks for denials in the future.

The majority of our admissions come from our ED, so we decided we would need to place a nurse case manager with UR background in the ED from 8 a.m. to 10 p.m. seven days a week. The ED nurse case manager's primary role was to work in collaboration with the ED providers to determine what admission status and level of care at which the patient should be brought in to the hospital.

As CMS continues to increase the number of RAC and MAC requests, the need to add additional appeal nurses with UR knowledge of InterQual and Milliman was required. With the MAC appeals being focused on pre-payment, the UR and appeal nurses are working in collaboration with the surgeons and physicians to communicate the standards of care being challenged and to develop systems that will prevent any future denials to be upheld.

When we had pre-payment denials for total knee replacement surgery, we reviewed our fiscal intermediary's expected documentation to support the medical necessity of this procedure. We then met with the orthopedic surgeons and discussed the development of a check-off list that would meet expected guidelines and support the necessary documentation required.

With the financial impact readmissions have on hospitals, we have hired two transitional care nurses to focus on the prevention of congestive heart failure (CHF) readmissions. They provide education to any CHF patient that will be discharged to home with no home health services. Before being discharged, CHF patients can weigh themselves, identify what change in their symptoms would require them to contact their physician and the importance to follow-up with an appointment with their PCP within 5-7 days of discharge.

The transitional care nurses call each CHF patient assigned to them within 3-5 days of discharge to review their medication list, discuss their diet, weight and any other changes in their CHF symptoms since discharge. Their appointment is confirmed and another call within two weeks is established. Our CHF readmission rate was 24 percent in FY 2011, 20.8 percent in FY 2012 and 19.8 percent for FY 13 to date.

Protecting Reimbursement

With the continued changes in the regulatory climate and reimbursement structure, your case management model must be able to adjust and align to meet the needs of your patients and hospital.

The triad model allows the nurse case manager to focus on facilitating the patient's transition to the next level of care without increasing their LOS because they are not being distracted by the need to complete UR reviews and submit them in a timely manner in order to prevent a denial. Being in a patient's medical record does not mean that one person can focus on care coordination, discharge planning, UR, prevention of denials, readmissions, accurate physician orders, admission status, level of care and other mandated regulations that have fallen on the case management department.

Use data to support and demonstrate the number of assessments and interventions that staff are involved with every day, and on how each activity can have a positive or negative impact on providing quality patient care and protecting your hospital's reimbursement.

1. Zander, K. (2008). Hospital case management models: Evidence for connecting the boardroom to the bedside. Retrieved Jan. 8, 2013 from the World Wide Web:
2. Maryland MOLST. How do I plan for my health care? Retrieved Jan. 8, 2013 from the World Wide Web:
3. New York State Department of Health. (2012). Medical Orders For Life-Sustaining Treatment. Retrieved Jan. 8, 2013 from the World Wide Web:
4. Novitas Solutions. (2011). Provider bulletins: Recovery audit contractor. Retrieved Jan. 8, 2013 from the World Wide Web:
5. Centers for Medicare & Medicaid Services (2012). Recovery audit program. Retrieved Jan. 8, 2013 from the World Wide Web:

Jan Lear is director of case management at Medstar Franklin Square Medical Center, Baltimore.

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