Managed care will continue to be a central topic in the national debate on
health care costs. Regardless of the current penetration of managed care into
your hospital's market, planning and implementing effective case management
now will help to ensure success in your inevitable competition for managed
care contracts. Health Systems Management Network believes that effective
case management is the key to managed care and will benefit the hospital,
payor, patient and physician alike.
Success in the managed care arena depends primarily upon an active case management
system. Your entire staff must work to ensure that all processes, from pre-admission
to billing, are integrated into a continuum of care to ensure that length
of stay is appropriate for each case and that no more or less resources are
allocated than are required. The reality is that this ideal often seems unattainable.
The complexities of changing payor requirements and patient acuities and complications
stress every hospital's case management system. Through successful engagements
at many acute care hospitals and integrated delivery systems, Health Systems
Management Network has shown that there are certain essential elements in
the development of an active case management system. Among these are the coordination
of care, clinical documentation, accurate data on utilization, clinical benchmarks
and critical paths. A comprehensive management plan and detailed organizational
support are key to the integration of all case management methods. Health
Systems Management Network can assist you in developing the management plan,
the organization and documentation systems to allow you to confidently negotiate
managed care contracts and find financial success in their fulfillment.
Critical paths have been shown to reduce costs, expedite reimbursement and enhance patient satisfaction. The development of critical paths is a four-step, iterative process. The process of selecting principal diagnoses and procedures for critical path analysis is a strategic one. Market demands, payor requirements and a detailed analysis of clinical practice through medical-record reviews must be weighed. Your institution's history on data such as length of stay and resource utilization should be examined against national, regional and competitive statistics to determine which procedures are likely to benefit the most. The second step is the assignment of a team to write a model critical path. We have found that this team should include medical, nursing, UR, quality and medical records staff. When a preliminary critical path has been developed, it should be pilot tested. Testing, with careful documentation, will allow the team to evaluate and revise its work. This process is a clear example of continuous quality improvement. But the importance of accurate and timely documentation to this process cannot be overstressed. Case management based on critical paths is a powerful tool for dramatic cost efficiencies. Effective documentation will allow for quicker development of a case management system and specific critical paths, better tracking of variances between actual care and that specified on the critical path, increased patient awareness and satisfaction, and enhanced revenue through careful tracking of complications and co-morbidities, improved resource management, reduced length of stay and strategic competitive advantages.
The development of a case management system is hospital-specific. As critical paths must avoid the perception of "cookbook" medicine, Health Systems Management Network believes that there is no cookbook for a case management system. Although we draw upon wide experience in acute care hospitals and integrated delivery, our work with you is based completely upon the realities of your institution and its market. In addition to our action-oriented management report, our engagement can include "hands-on" assistance in the implementation of our recommendations, thorough training and periodic progress reviews.
