By: Dr. Pariksith Singh, MD. May 2021
Creating a Care Management (CM) program entails several requirements. But, first, it must define the goals. The goals, to my mind, are:
Creating a team is the next step. A strong CM program needs to have experienced and dynamic CM leadership including doctors, medical officers, case managers, nurses, care coordinators, referral managers, and medical assistants who are constantly educated and trained in the latest developments in health care policy.
The location of CM services should preferably cover as many points of service as possible, including hospitals (where embedded case managers along with hospitalists bring optimum results), skilled nursing facilities (SNFs) where again, embedded case managers along with SNFists bring optimum results, home and assisted living facilities (where home visits by providers for high-risk patients might be of great value along with following up by case managers and care coordinators along with home health care over the phone or by home visits might be very effective) and office settings (where the providers and the whole office team needs to be onboard).
CM necessitates the integration of various aspects of health care including regulatory, compliance, operational, clinical, technical, and financial. All these need to be considered and brought together for the best results. Constant monitoring of the program is essential. Looking at reports from the hospital, especially opportunity days, GMLOS, hours in observation, re-admits, ER visits, mortality and morbidity, core measures, patient engagement scores, and outcomes are critical. Similarly, from SNFs, re-admits, falls, decubitus ulcers, UTIs, patient satisfaction, and length of stay are of great value.
Medicare generally tracks and reports the length of stay as a “Geometric Mean Length of Stay” or GMLOS. Most hospitals measure their length of stay as an “Average Length of Stay” or ALOS. So why does Medicare use the GMLOS? The advantage of the GMLOS is that it will minimize the impact of outliers. If the number of patients is relatively low, one patient with an uncharacteristically long or short LOS will significantly increase or decrease the ALOS respectively, but the effect on the GMLOS will be less. Medicare has to determine “appropriate” LOS based on a large amount of data that includes outliers on both extremes. The goal is to get to a number that can be utilized in the DRG payment formula. GMLOS is the best method for that purpose. Hospitals generally track ALOS and compare that to the GMLOS.
For managed and accountable care, the cost of care compared to the premium, utilization of generic drugs, patients seen post-discharge from hospitals and SNFs within seven days, multiple ER visits, time taken for a referral to be done, high risk and catastrophic cases should be regularly reviewed. Appeals and grievances need to be followed along with complaints about offices, providers, and staff, by the formulation of a case tracking mechanism.
Care management needs to be one leg of a three-footed stool, the other two legs being - compliance and quality. This is the holy triangle of sorts in managed care. The other important triangle is comprised of billing/coding, data, and analytics. Billing and coding give critical information about patient diagnoses and risk stratifications, special needs, and specific disease management. Data is the new oil, they say, in the new world of information technology but for those of us in health care, it is our lifeblood. Without strong data organization and analytics, no CM program will achieve its fullest potential.
Operations: Workflows might include reviewing reports from health plans or billing data to identify patients at high risk or with specific conditions. They may also include referrals from providers or case managers from offices, hospitals, or SNFs in specific cases. Referrals that do not meet CMS criteria should be reviewed by case reviewers with expertise in LCDs and NCDs and experience in case management. Case managers should track the sicker patients. Referrals that do not meet LCDs or NCDs need to be referred to health plans for medical determination following ODAG policies. Care coordinators should work in conjunction with case managers and providers to create another line of communication with patients. Patient advocates who may be case managers or relationship managers also are part of the team.
Hospital case managers may work with physician advisers and hospitalists to review cases to ensure proper utilization of resources as needed. Any patient who does not meet the criteria for a further stay in the hospital or SNF needs to be given proper notice and may not be discharged without due process.
Transitional care management is another emerging area that needs to be assessed along with the use of IoT (Internet of Things) and apps at home. Executive care management may be comprised of specialist providers who only see patients with certain diseases or for their initial office visits. Devices can be provided to patients for better self-management including blood sugar and blood pressure monitoring devices, weighing scales, and possible avenues of telemedicine that may be explored.
The key is for the program, as it is developed, to constantly grow, adapt, learn, and re-learn, challenge itself and align all the incentives so that true team effort can be maintained. The right leadership is the sine qua non to establish the right culture and direction of the program.
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