OHIO
Case Management
Business Management
We will get your patients home again, faster and stronger. Chef-prepared meals, private suites and personal concierge service. This is rehab? Our Home Again rehabilitation program will pamper your patients while they undergo therapy following surgery or illness. Once they are ready to return home, we will provide them with a unique Personal Wellness Plan to educate them on their diagnosis and reduce their chances of being re-admitted to the hospital. To find out how we can help your patients transition smoothly back home, call us to schedule a personal tour.
For a full list of our Ohio locations, please see the facing page. For a full list of our Ohio locations, please see the facing page. Call a campus near you for more information about their services. Fora acampus full list of ouryou Ohio please seeabout the facing page. Call near forlocations, more information their services.
Trilogy Health Services Ohio Locations Briar Hill North Baltimore, OH 45872 Phone: (419) 257-2421
Meadows of Kalida Kalida, OH 45853 Phone: (419) 532-2961
Cypress Pointe Englewood, OH 45322 Phone: (937) 836-3149
Meadows of Leipsic Leipsic, OH 45856 Phone: (419) 943-2103
Forest Glen Springfield, OH 45503 Phone: (937) 390-9913
Meadows of Ottawa-Glandorf Ottawa, OH 45875 Phone: (419) 538-6529
Forest View Zanesville, OH 43701 Phone: (740) 454-4663
Willows at Bellevue Bellevue, OH 44811 Phone: (419) 483-5000
Genoa Retirement Village Genoa, OH 43430 Phone: (419) 855-7755
Willows at Willard Willard, OH 44890 Phone: (419) 935-6511
Richland Manor Bluffton, OH 45817 Phone: (419) 643-3161
Triple Creek Colerain, OH 45231 Phone: (513) 851-0601
Springview Manor Lima, OH 45805 Phone: (419) 227-3661
Valley View Fremont, OH 43420 Phone: (419) 332-0357
The Heritage Findlay, OH 45840 Fax: (419) 424-2010
Highland Oaks McConnelsville, OH 43756 Phone: (740) 962-3761
Lakes of Monclova Maumee, OH 43537 Phone: (419) 866-3030
Village Green Greenville, OH 45331 Phone: (937) 548-1993
Meadows at Putnam Acres Ottawa, OH 45875 Phone: (419) 523-4092
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Partners in HIGH FINANCE A solid relationship between case management and revenue cycle management can translate into better care and a healthier bottom line.
departments 8
Business Development 9 Powerful Online Resources for Patient Care Coordinators
Editor Elizabeth Page Contributing Editors Pamela Parker with Daybreak Ventures Sean Muldoon, MD Richard C Senelick, M.D. with Healthsouth Art Director/Graphics Dustin Smith
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Our Friends DFW CMSA dfwcmsa.org Advertising 972-835-1208 Publisher Frank del Basque
Copyright Š Case Management Magazine, LLC, all rights reserved. No part of this magazine may be reproduced or transmitted in any form or by any means without written permission from Case Management Magazine, LLC. Printed in the USA.
For more information on Case Management & Social Worker Patient Resource Guide email: frank@casemanagementconnector.com
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Southern ohio Valley CMSA Soaring to new heightS with CASe MAnAgeMent SAturdAy, April 13th, 2013
online earlY BirD registration closes march 31st, Don’t miss these great Discounts! online regular rate registration closes april 13th! register on line: sov-cmsa.org
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Partners in High Finance A solid relationship between case management and revenue cycle management can translate into better care and a healthier bottom line. As hospitals look for ways to improve the quality of care while also boosting revenue, the case management and revenue cycle management (RCM) groups are partnering more frequently. The functions that fall within case management vary by institution and how the group interacts with RCM depends largely on which responsibilities are in case management’s bucket. Because connections to RCM differ so widely, Steven L. Robinson, MS, PA, RN, CPUR, senior director of clinical documentation improvement (CDI) solutions at Maxim Health Information Services, says case management might have a huge link to RCM in one hospital but little direct influence in another. The two groups will always have an indirect relationship, though. “For instance, some case managers take on the role of the clinical documentation specialist or utilization review or looking at denials,” says Robinson, adding that at least one-half of all CDI programs are housed in the case management department. In that scenario, case managers are by default a direct part of the front-end revenue cycle. Steve Everest, executive vice president of Prognosis Health Information Systems, says the healthcare ecosystem is evolving, leading to a shift in the roles played by case management and RCM as well as how those responsibilities fit together and overlap. “As the industry changes and as the landscape changes a little bit with federal funding, case management is being pushed toward understanding the revenue cycle pieces,” he says.
A Shift in Roles In the past, case managers focused predominantly on the clinical aspects of a patient’s visit. However, today they’re increasingly being drawn into discussions about copays, coverage levels, and a patient’s ability to pay. “The smart hospitals are the ones 4 | C a s e m anagementconnector.com
that are doing that work ahead of the game,” Everest says, meaning the case management team is involved in making sure the current financial picture is what the hospital wants while at the same time ensuring patients get the clinical outcome they need. “We see that line between pure case managers and pure revenue cycle people blurring, and we see people wearing both hats.” Based on her experience working in the revenue cycle, Carla Engle, MBA, director of product management at Emdeon, says case management’s role was broader several decades ago. “They were being charged with controlling cost by improving quality,” she notes. Over time, case managers narrowed their focus to utilization review and discharge planning. The pendulum now seems to be swinging back the other way, and case management is once again taking on a wider role. “I see case management really working in all aspects of the revenue cycle,” says Engle, who lists five primary areas where it has the greatest impact: preadmission, admission, concurrent review, discharge, and postdischarge. “There are things that case management does that touch all of those steps.” The case management team may have strong ties to RCM, but it’s just one group involved in daily decision making, says Diane L Reidy, RN, BSN, MN, MHA, director of the clinical case management department at Lyndon B. Johnson General Hospital in Houston. “We interface with coding; we interface with physicians. There are several departments we work with on a regular basis,” she explains. Any time a change occurs, such as when new computer programs are deployed that impact the workflow between the functional groups, Reidy says her team meets with RCM and any other affected groups to proactively discuss how they can best work together moving forward. The conversations focus on
a “let’s talk about what’s working and what’s not” approach, she says. The touch points between case management and RCM begin in the preauthorization phase, where Everest says healthcare organizations are increasingly interested in confirming benefit levels as well as a patient’s capacity to pay. The mission to be more proactive in determining a patient’s financial picture is being joined by the hospital’s desire to ensure it has the appropriate facilities and equipment for proper treatment. It’s all about the type of patient, according to Everest. “Who’s their payer? What does that payer expect? And what will the payer tell us about the patient up front before they darken our door?” he says. Outside the emergency department (ED), where preauthorization is moot, the emphasis is on being proactive. “Case managers are expected to take a role in that and bond with the revenue cycle folks to figure those things out,” Everest says.
Medical Necessity Upon admission, the collaboration between case management and RCM ramps up, says Melanie Endicott, MBA/HCM, RHIA, CDIP, CCS, CCS-P, an ICD-10-CM/ PCS trainer and director of HIM solutions at AHIMA. “That’s when the determination is made if they meet inpatient medical necessity or if they’re an outpatient,” she says. While the case manager generally is not the sole person determining medical necessity, it’s another link in a chain of instances where case management and RCM work together. “Sometimes the patient may come in as an outpatient and later get converted to an inpatient. Again, that needs to be looked at,” says Endicott, adding that as the patient moves through the process, several factors will affect how much interaction is necessary between case management and RCM. “The more complicated cases will require increased interaction between the case managers and physicians to ensure that the patient’s treatment plan is carried out appropriately so the patient receives the best quality of care,” she notes. Rather than throwing case management and RCM together and simply telling them to collaborate, Engle says everyone benefits from a carefully constructed plan. “I think
there needs to be a clear protocol established about where case management gets involved,” she says. Engle encourages healthcare organizations to develop policies to define case management’s role and where it intersects on both the clinical and financial sides. This will address case management’s exact responsibilities and identify potential gaps in its relationship with other departments. “The hospitals that have the best practices have a very clearly delineated process about where case management is involved on the inpatient and outpatient perspectives,” she says.
Record Reviews Establishing a process that includes a thorough review of records is crucial to a strong and proactive communication stream between case management and RCM. Because the majority of inpatient admissions are based on diagnosis-related groups (DRGs), Robinson says it typically falls to concurrent reviewers to identify which working DRG is assigned. As case management and RCM work more closely together, case managers are increasingly involved in that process. “If case managers take on the role of the CDI specialist, they will assign that working DRG or initiate a discussion to clarify which DRG should be assigned,” Robinson says. The case manager then follows the progression of a patient’s symptoms and diagnoses. If the physician hasn’t provided enough clarity, Robinson says the case manager would then query him or her on specific causes as needed. Records review—and how case management and RCM work together to ensure documentation addresses the needs of both groups—isn’t something you can set and forget, Reidy says. “Most of our processes have changed because in the latter part of 2010 we implemented an electronic medical record system,” she says. “[As a result], you have to look at everything you’ve been doing in the past and ask why you did it that way. It’s one of the things we’re still polishing.” Determining which points will be reviewed in the medical records doesn’t involve just case management and RCM. Endicott recommends other functions such as CDI and utilization review also take part. “And it’s not just one person making that decision [of what to review],” she says. “It’s having casema n a g e m e n t c o n n e c t o r . c o m |
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the experts that know the revenue cycle work with those in case management to determine that checklist.” Such a process can ensure the necessary information is present and accounted for in the file. For example, are admit orders where they need to be? Were all the complications documented? Is the correct discharge disposition in the chart? “It’s a team approach,” Endicott says. “It’s not just one department doing it.” The proactive component to records review is perhaps the key benefit to both case management and RCM. “I think the biggest thing is just preventing stoppage from happening on down the line,” Engle says. Rather than expend energy with postdischarge denials and appeals on the back end, thorough reviews by both groups can help business operations flow smoothly. That’s a plus for the administrative process as well as the hospital’s revenue stream. “As they’re doing concurrent record review, they’re really making sure a denial is not going to happen,” Engle explains. Where do medical necessity and length-ofstay approvals factor into the equation? Engle says the majority of denials she witnessed during her work as an auditor related to medical necessity. “I think case management plays a huge role in ascertaining medical necessity right from the get-go,” she says. “They make sure there aren’t going to be any problems. It prevents those denials on the back end.” According to Engle, concurrent reviews while the patient is still in-house translate to fewer appeals and denials being triggered. RCM teams often spotlight high-utilization cases that require more resources and longer stays. “Those are the things that, as a case manager, you have to find the balance between the financial side, longer length of stay, and higher utilization of resources vs. patient care,” Engle says.
Location Matters When it comes to medical necessity and length-of-stay approvals, Everest says urban environments typically lend themselves to higher levels of proactive collaboration between case management and RCM. For example, a client in a large Oklahoma city preauthorizes every account because it 6 | C a s e m anagementconnector.com
makes sense from both the case management and RCM perspectives. “They make sure that they run credit checks on the patient because they are an elective surgery facility,” he says. This strategy also saves the hospital from going through the steps involved in registering patients and preparing them for a procedure only to find out they can’t afford their payment portion. “We’re seeing the case managers get involved with that process— that proactive, up-front process—before the treatment begins whenever they can,” Everest says. The approach in the community hospital market in rural America differs from that of urban facilities. In the rural setting, Everest says the group of physicians practicing nearby is often quite small, and the patient population being served is typically a known quantity. “It’s almost a given that we know what kind of patients this physician is going to treat, and we know with a high level of probability what their outcome is going to be,” he explains.
Working Arrangements Discharge dispositions and final diagnoses often are understood early in the process. In those cases, Everest says case management and RCM may work together in a unique fashion. “Some of our clients are opting, if it’s not a significant outlier in terms of dollars, to absorb [the cost] rather than irritate the local community,” he says. Identifying the number of days allowed in the hospital is generally a function Robinson sees in the realm of case management. “That used to be the old utilization review function, but now it’s largely been incorporated into the role of the case manager,” he says. If they’re not able to identify the length of stay up front, sometimes they “will also have the responsibility of calling the insurance company to see if the patient is allowed extensions on their stay,” Robinson says. Medical necessity, length-of-stay approvals, and the actual duration of the patient’s stay directly impact the bottom line in the long term. “Revenue cycle does have ultimate responsibility for those functions,” Robinson says.
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Powerful Online Resources for Patient Care Coordinators Resources for patient care coordinators, from case managers to social workers and discharge planners, can at times be difficult to comb through. Not all online information is particularly helpful, and precious few resources offer top-quality information to make the life of the patient care coordinator a little bit simpler (even fewer for free!). To help hospital professionals, we've come up with a top ten list of websites that provide you, the patient care coordinator, with some powerful tools - and with critical information that can be shared with patients and their families to facilitate care. 20 Tips to Help Prevent Medical Errors Caregiver and patient communication is emphasized in this helpful handout, which underscores cooperative ways to help ensure care is properly implemented. This resource allows the patient to take a hand in his or her own medical care, and offers reassurance that healthcare professionals are operating in the patient's best interests. ahrq.gov/consumer/20tips.pdf Advance Care Planning: Preferences for Care at the End of Life The Agency for Healthcare Research and Quality offers this end-of-life care guide as a way for healthcare professionals to help patients navigate decision making. Available for download, this research-heavy informational booklet also includes a list of additional resources. ahrq.gov/research/endofliferia/endria.htm BOOSTing Care Transitions Resource Room BOOST, which stands for Better Outcomes by Optimizing Safe Transitions, is a website that offers a wide variety of materials aimed at enhancing the discharge process. The website is full of resources, evidence-based medical case studies, fact sheets, and implementation guidelines. hospitalmedicine.org Caring for the Elderly This guide from the New York Times lists webbased tools for use by the elderly and their caregivers. Government help sites, housing services, legal and financial guides, and advocacy groups are a few of the 8 | C a s e m anagementconnector.com
categories you'll find, many of which include stepby-step instructions and care planning and tracking applications. nytimes.com/ref/health/noa/resources.html Case Management Society of America The Case Management Society of America is the leading membership association providing professional collaboration across the healthcare continuum to advocate for patients’ wellbeing and improved health outcomes by fostering case management growth and development, impacting health care policy, and providing evidence-based tools and resources. cmsa.org HHQI National Campaign The Home Health Quality Improvement National Campaign is chock full of data reports, evidence-based tools, continuing education, and webinars aimed at improving medication management and reducing unnecessary re-hospitalization. homehealthquality.com Palliative Care Tools, Training, and Technical Assistance The Center to Advance Palliative Care offers their guide to building a palliative care program at this helpful website. Furthermore, it offers tools such as training and mentoring, links to national seminars, and a subdivided list of hundreds of palliative care research and reference links. capc.org Project RED (Re-Engineered Discharge) Boston University Medical Center founded the RED research group to develop strategies and improve and enhance the discharge process. Their toolkit is a free downloadable resource that "provides complete implementation guidance and is adapted to address language barriers, cross cultural issues and disparities in health care communication and trust." bu.edu.fammed/projectred/index.html Your Discharge Planning Checklist "For patients and their caregivers preparing to leave a hospital, nursing home, or other care setting," this packet available for download from the Official U.S. Government Site for Medicare includes discharge checklists for the patient and caregiver, an area to list medication instructions, an appointment roster, and additional information. medicare.gov/publications/pub/pdf/11376.pdf These websites can help discharge planners to make the most effective choices for their patients.
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