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Scope of Services

What is Case Management?

Case management in hospitals and health care delivery systems represents a wide range of services and diverse methods of organizational structure. The concept of case management conveys different meanings to individuals and to organizations. ACMA describes case management in the following context.

Definition of Case Management

Case Management - in hospital and health care systems is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient’s right to self-determination.

CONTEXT

In an effort to describe the varied functions that are considered case management services, a task force was assembled to compile a collective of what ACMA considers to be the Scope of Services for Health Care Delivery System Case Management. The task force solicited input from ACMA members and created a representative listing intended to describe and associate the vast nature of case management in various facilities throughout the country. The Scope of Services Task Force presents this list with the caveat that it is not intended as a “mandated” list of expected case management services for all to provide, but rather a compilation of case management services typically provided by health care delivery systems. ACMA does not intend that this Scope of Services be a description of a case management department’s responsibilities. ACMA recognizes that organizational structures 3 www.acmaweb.org frequently designate a service as a department. The ACMA Scope of Services represents the functions and responsibilities associated with the case management services that are provided to our patients. These services may be provided either primarily by case managers or secondarily by others. However, all are closely aligned with case management as defined by ACMA.

Scope of Services

The following categories best reflect this concept:

  • Education
  • Care Coordination
  • Compliance
  • Transition Management
  • Utilization Management

The following further describes the functions of each Service:

Education

For all patients requiring active case management services, case management is expected to ensure and provide education relevant to the effective progression of care, the appropriate level of care and safe patient transition.

Specifically:

  • Ensure that education regarding the injury/clinical/disease process has been provided by the health care team
  • Provide information to the health care team, patient/family/caregiver regarding available resources and benefits for acute and post-acute services that ensure patient choice and a safe and timely transition
  • Identify clinical, psychosocial and/or operational learning opportunities that negatively affect care or reimbursement and provide the health care team, community partners, patient/family/ caregivers education that will address or resolve the issues

Care Coordination

Case management is expected to have a defined method for screening/identification and assessment of patients in need of case management services. Additionally, case management must have defined standards for ongoing monitoring and interventions that advance the progression of care and must include the clinical, psychosocial, financial and operational aspects of care.

Screening/Identification

  • Case management will screen all patients for clinical, psychosocial, financial and operational factors that may affect the progression of care and through the use of identification criteria stratify patients at risk/ barriers/ strengths or in need of case management services

Assessment

  • Case management must have a defined case management assessment tool that expands the case managers’ knowledge of the risks identified in the screening process and is complementary to the assessment of other clinical disciplines

Plan of Care

  • Case management will review and ensure the plan is clinically appropriate and matches the patient’s care needs and is consistent with patient choice and available resources

Sequencing

  • Case management will help ensure consults, testing and procedures are sequenced in a manner that is appropriate to the patient’s clinical condition and supports timely and efficient care delivery. Case management will actively intervene and resolve/escalate where barriers to service exist

Communication

  • Communication both verbal and written is the foundation on which knowledge transfers, and collaboration and relationship building is based
  • Case management organizational structure and staffing, policies and procedures must meet the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation
  • Case management is responsible for documenting information that is not duplicative but instead is complementary and contributes to the progression of care

 

Compliance

Case management will be knowledgeable of and ensure compliance with the federal, state, local hospital and accreditation requirements that impact their scope of services.

  • Case management organizational structure and staffing, policies and procedures must meet the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation
  • All disciplines practice within the scope of practice as defined by state licensing regulations

Transition Management (Transitions of Care)

Based on the health care team's assessment and patient choice and available resources, the case manager is expected to integrate these key elements and develop and coordinate a successful transition plan. Transition management planning begins at the time of case management’s initial patient encounter (preadmission, admission, emergency department, etc.) and is reevaluated and adjusted throughout the patient’s hospital stay.

Transition Coordination – Identification

  • Based on assessment, case management will identify patients with post-acute needs including those at risk for readmission and prioritize as well as intervene as needed
  • For those patients at risk for readmission, case management will apply interventions to proactively prevent readmissions and evaluate those who are readmitted to identify and implement strategies for improvement

Community Partnerships

  • Case management will identify available community resources/potential partners and advocate for resolution of gaps in the available resources and processes
  • Case managers will be knowledgeable of and provide available information for patients to make an informed choice regarding resources/providers

Transition Coordination

  • Case management will arrange/ensure all elements of the transition plan are implemented and communicated to key stakeholders including, but not limited to, the health care team, patient/family/ caregiver, and post-acute providers
  • Case management will convey all necessary information for continuity of care and patient safety, verify receipt and provide a venue for additional questions and/or information requests/needs

Follow-Up

  • Case management will provide electronic, telephone, in person method of contacting the patient/family to validate the success of the transitional care plan within 72 hours

Utilization Management

Case management is expected to advocate for the patient while balancing the responsibility of stewardship for their organization and in general, the judicial management of resources.

Medical Necessity

  • Case management will have a defined method to ensure the patient is in the appropriate “status” and level of care for the patient’s clinical condition. The process must include a method for secondary physician review when warranted

Payer Interface

  • Case management with respect to payer requirements will ensure timely notification and communication of pertinent clinical data to support admission, clinical condition, continued stay and authorization of post-acute services. When a lack of concurrence exists between the patient’s needs and the payer’s authorization, Case management will advocate securing reimbursement/ resources needed for patient care. When no payer authorization requirements exist, case management accepts the role as a patient and organizational advocate to manage the utilization of resources

Avoidable Delays/Days

  • Case management will utilize a validated system/defined methodology for tracking avoidable delays/days and use this information to identify and communicate opportunities for improvement. Case management will participate in the development of performance improvement activities relevant to identified opportunities

Denials/Appeals

  • Case management will proactively prevent medical necessity denials by providing education to physicians, staff and patients, interfacing with payers and documenting relevant information
  • Case management will provide the clinical information necessary for the appeals process of cases for which medical necessity denial has been received
  • Case management will utilize escalation process as needed

 

GLOSSARY

Case Management:

in hospital and health care systems is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient’s right to self-determination.

Assessment:

The identification and documentation of the patient’s initial transitional care needs within 24 hours of admission for the following elements:

  • Medical necessity for patient status and level of care
  • Psychosocial needs
  • Clinical needs
  • Anticipated discharge needs
  • Spiritual needs
  • Patient/family/caregiver health care level of understanding

And the amalgamation of the key elements into an initial transitional care plan with alternatives.

Care Coordination:

A process whereby assessment, planning and interventions effectively integrate, ensure and advance the plan of care to support successful transitions.

Clinical Intervention:

An intervention carried out to improve, maintain or assess the health of a person, in a clinical situation.

Intervention:

  • Carries out individual interventions
  • Communicates and resolves barriers
  • Utilizes escalation process as needed
  • Provide the necessary elements of clinical and psychosocial information that minimize the potential for readmission
  • Implement and continually modify as needed the transitional care plan
  • Provide clinical and psychosocial interventions as needed
  • Ensure and reinforces proactive patient/family/caregiver education

Live Follow Up:

Electronic, telephone, in person method of contacting the patient /family/caregiver to validate the success of the transitional care plan typically within 72 hours.

Monitoring:

  • The act of reassessing minimally every 48 hours
  • Utilizing a high-risk stratification system, ensure a post-discharge live follow-up within in 72 hours for all identified patients

Planning:

  • Assures designation
  • Ensures timely sequencing
  • Elicits and incorporates elements necessary for transitional plan of care
  • Develops the transitional care plan, incorporating patient’s short and long term goals

Professionalism:

Consistently demonstrates behaviors that result in credibility and respect for the individual and the case management practice.

Psychosocial Intervention

Assesses & intervenes to address psychosocial issues associated with hospitalization & transition plans.

  • Assesses & intervenes, focusing on emotional/coping style, identification of patient/family resources and obstacles for complex psychosocial situations
  • Utilizes clinical skill and expertise to provide assessment, intervention, and where appropriate, reporting for complex abuse, neglect, domestic violence and sexual assault situations
  • Provides clinical social work assessment and intervention for complex crisis, mental health, substance abuse, adjustment and grief/loss situations
  • Provides specialized knowledge and expertise for complex resource and benefit situations
  • Assists other team members to understand and appreciate a patient and/or family's reaction to a serious illness, injury, and/or chronic illness/ disease as well as family and other environmental dynamics affecting care, treatment and compliance
  • May develop and facilitate support groups

Reassessment:

Ongoing reviews for medical necessity and adjustments to the transitional care plan as needed and minimally within every 48 hours.

Resource Management:

Balances cost and quality through the effective evaluation and utilization of fiscal, human environmental, equipment and service options available to the patient.

Transitional Care Plan:

The plan to move the patient along the care continuum including pre admission inpatient post-acute and community.

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