Improving patient care delivery with integrated case management

Healthcare Financial Management, Dec, 1996 by L. Greg Cunningham, Martha J. Koen

Providers and payers in an integrated delivery system can increase the coordination and cost-effectiveness of the services they provide by developing a strong case management program.

Integrated case management can provide the common thread for developing and meeting joint goals, such as reduced lengths of stay, cost-per-case reductions, decreased admission/readmission rates, and increased patient satisfaction.

Providers and payers should design and integrate their case management services to allow for greater sharing of resources and integration of patient care goals and incentives.

Traditionally, patient care has been provided through a fragmented system of episodic illness management. Each provider and provider department essentially managed its own operations according to its own set of priorities. Payers providing cost-based reimbursement offered no incentives for providers to coordinate care among departments or facilities in order to reduce costs.

Managed care is changing these entrenched healthcare traditions. Providers and payers alike are acutely interested in reducing the cost of care. One of the tools that can be used to reduce costs is case management. Case management goes beyond traditional utilization review and discharge planning to focus on operational, as well as clinical, issues. Case managers identify bottlenecks and problems in care delivery that affect patient outcomes and associated costs and collect and analyze data necessary to support problem resolution.

For example, a case manager might note that patients who have undergone total knee replacement surgery do not progress as quickly as they could, and after analyzing the situation, may determine that this lack of progress is due to the absence of physical therapy services on weekends - an operational arrangement that has direct clinical implications.

The case manager might then collect outcomes data for patients who received continuous therapy compared to those whose therapy was interrupted on the weekend. A multi-disciplinary team could then use the data to examine options for providing weekend therapy or ambulation that would result in improved patient outcomes and/or decreased costs.

Case Management at the Hub

Healthcare staff are typically suspicious of management initiatives that reduce their autonomy to make decisions, particularly decisions related to direct patient care. Therefore, positioning case management as a problem-solving and facilitating tool, as opposed to a "watchdog" or auditing function, will encourage its acceptance.

It is important to emphasize that case managers can provide an overview of all of the activities that contribute to patient care, and therefore are able to offer solutions to both clinical and operational bottlenecks. The more that case management can be positioned neutrally, with its only goal being the best clinical outcomes at the lowest cost, the more effective the program will be.

Sharing Resources

Payers and providers should work to share resources to create a comprehensive database of information relevant to case management. Combining provider medical and cost information with payer financial information and practice guidelines can help an IDS track total treatment costs, provider performance by facility, physician practice patterns, chronic disease management trends, and other data beneficial to case managers and IDS executives. Since an IDS typically has case managers at several of its facilities, this information sharing can facilitate the quality and cost-effectiveness of the care a patient receives throughout the IDS.

To ensure that the same data are available to payers and to each entity in an IDS, information standards must be established. The standards should address:

* What types of information will be tracked;

* How the information will be documented;

* Who will be responsible for collecting the information;

* How the information will be disseminated; and

* How often routine information transfers will take place.

These information standards can help ensure a common-language transfer of information and the establishment of consistent information tracking mechanisms.

Coordinating Payer and Provider Case Management

Because the roles and incentives of provider and payer case managers normally have been different, the question of "who controls the case" has been a problem. Payer case managers, particularly those affiliated with HMOs that are not part of an IDS, often function simply as benefits managers who inform providers about the practice protocols that have been established and the types of care for which costs will be reimbursed and denied.

However, when payers and providers are part of the same IDS and have aligned their goals and incentives, the question should become moot. But, while the need for payers to maintain a "watchdog" case manager may decrease, payers still will want to ensure that providers achieve high levels of quality care and patient satisfaction so that employers will not switch plans.