The importance of hospital and health system case management has grown exponentially over the past 10 years and is now getting attention from leaders throughout the healthcare industry. Case management is the department where clinical and financial workstreams intersect, and teams are uniquely equipped to respond in situations where revenues are tight and patient outcomes and experiences are paramount.
To maximize the effectiveness of your case management team, it is important to not weigh them down with responsibilities that do not consistently fall in their department. While responsibilities of case management have expanded due to the increasing pressures of healthcare and advancement of prospective payment programs, it is important to maintain strong performance in the core responsibilities. Case management core responsibilities are outlined below:
- Obtaining clinical authorizations - Through partnership with your business office, case management plays a foundational role in ensuring your facilities receive proper authorization for services provided in the inpatient, observation and surgical environments. While the majority of work is focused on obtaining inpatient authorization, it is necessary to have a defined process across your system to ensure proper attention is provided to each service area. To ensure consistency, define who is responsible, how quickly and often information should be provided to payors and where it should be documented.
- Establishing safe and effective transitions in care through care coordination - Much more than simply discharge planning, case managers and social workers need to lead and support the development of plans in managing patients' transition throughout an episode of care. It is case management's role to evaluate potential plans, develop them alongside the physician/care team and ensure they are enacted in a timely, efficient and effective manner. With risk contracts being more prevalent daily, this activity is key and now must be managed from initial presentation to acute discharge to return to post-acute level of care. Effective coordination and communication are expected by today's patients, and case management must lead this charge.
- Effective Utilization Management - Done appropriately, this is more proactive than utilization review and more than appropriateness of inpatient vs observation. It's more deeply evaluating levels of care, such as ICU vs Step Down vs Med/Surg. In the most advanced approach, it involves determining appropriateness of test and pharmaceutical utilization, ultimately leading to reducing care variation. The advanced stages of utilization management can be tough and scary if culture is not established and defined. This approach should not be seen as challenging providers in their delivery of care, but as supporting the care team in delivering high quality care with the most effective use of resources.
- Clinical Denial Management - Effective processes managing the above will help limit denials, but it won't stop them. Denials will always be present because frankly...payors will be payors. However, the stronger the above processes, the more prepared your system will be to prevent denials or appeal them after they have been issued. To succeed in this area, it takes focus and rigor. Ensure you have established processes in initial capture of denials, timelines for follow-up, tracking of why they are being received and overall results of appeal success. Monitoring work in denial management is key in many areas and can be powerful data for your senior leaders when it comes to payor contract negotiation.
The list could continue, but the focus was to highlight the core functions effective case management programs have in place. Case management is an exciting journey, and there is not one model or approach that works for every system. The key is to understand the responsibilities of your team, establish key performance indicators and then design staffing and process approaches to succeed.