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Best Practices in Contemporary Case Management
Best Practices in Contemporary Case Management
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In a post-ACA world, where resource utilization and health outcomes are increasingly measured and rewarded, the healthcare case manager is the cornerstone of care delivery. Consider these outcomes from real-world case management programs:

  • 25 percent reduction in specialist visits.
  • Percentage of individuals at highest level of patient activation more than doubles.
  • $400 PMPM savings for case management enrollees and 4:1 ROI.
  • Fewer admissions denials and reduced lengths of stay for ED treat-and-release and admitted patients.

Best Practices in Contemporary Case Management examines three separate case management initiatives that generated these results and others, detailing the impact of these programs on health outcomes, care delivery and resource utilization.

Healthcare organizations are positioning case managers along the healthcare continuum — and at routes of entry — to coordinate care for complex patients, manage transitions between care sites and reduce avoidable consumption of health resources. Embedding a case manager at the point of care is increasingly good business.

Market research conducted by the Healthcare Intelligence Network indicates that 91 percent of survey respondents rely on case managers in daily operations, while another third will add case managers to their staff mix in the coming year.

The 60-page Best Practices in Contemporary Case Management details these three current case management approaches:

  • Care coordination and disease-specific management is a winning combination. Jan Van der Mei, RN, MS, ACM, continuum case management director at Sutter Health Sacramento Sierra Region, shares Sutter Health's best practices in patient contact, inpatient monitoring and follow-up for its case management initiatives for patients with heart failure and diabetes. She also shares details from Sutter Health's care coordination/medical office case management for patients with chronic illness.

  • But sometimes, a complex case management approach works best, particularly when individuals have co-morbid chronic conditions as well as social morbidity. To assist organizations in identifying, monitoring and managing these target populations, Rebecca Ramsay, BSN, MPH, senior manager of care support and clinical programs at CareOregon, describes the team-based approach CareOregon employs to segment patients into different buckets based on patient complexity to ensure that case management resources are allocated effectively. She also describes how the addition of a paraprofessional case manager known as a 'healthcare guide' is supporting patients' transitions from hospital or skilled nursing facility to home.

  • And finally, contemporary models of case management are paying closer attention to healthcare routes of entry. In Lutheran Medical Center's case, that means embedding a case manager in its emergency department as the first line of defense in determining medical necessity and reducing the number of claim denials for a hospital. Toni Cesta, Lutheran's senior vice president of operational efficiency and capacity management, explores how to effectively structure an ED-based case management program and the potential impacts of an embedded case manager in the ED.
This resource provides details on:
  • Strategies, tools and technologies to assist in patient monitoring and follow-up;
  • What and when to monitor;
  • Data collection and tracking for program outcomes;
  • Techniques to engage non-compliant patients;
  • Identifying those at risk for high utilization and complex cases through multiple methods;
  • Understanding the population being served to determine the case management approach, interventions and staff resources to use;
  • Standardizing interventions and decision-making in case management;
  • Recruiting, hiring and educating case managers for effective outcomes;
  • Engaging case management patients through motivational interviewing techniques;
  • Encouraging patient self-management in the case management process;
  • Monitoring and managing the case manager and the patient;
  • How to identify the ED patients that would benefit the most from case management interventions;
  • The most effective ways to staff ED case managers and social works;
  • The role of the RN case manager and social worker in the ED;
  • The clinical and financial benefits of ED case management;
  • Complying with regulatory requirements for ED case management;
and much more.

Table of Contents

  • Long-Term Complex Case Management
    • Team-Based Case Management Programs
    • Using Predictive Models to Identify High-Risk Populations
    • Four Conditions Used to Classify Members
    • Using Questionnaires to Determine Care Plans
    • Five Domains of Patient Assessment for Case Selection
    • Effective Staffing of Case Management Teams
    • Monitoring Case Manager Performance
    • Calculating Program ROI
  • Inpatient Monitoring to Improve Care Coordination
      Key Elements of Care Coordination
    • Goals of Care Coordination
    • Focus on Care Transitions
    • Heart Failure Care Coordination
    • Diabetes Care Coordination
  • Embedding a Case Manager in the Emergency Department
    • 3 Goals of ED Case Management
    • Roles and Functions of the ED Case Manager
    • Dealing with High Utilization ED Patients
    • EMTALA and the ED Case Manager
    • Measuring Success from an Embedded ED Case Manager
  • Q&A: Ask the Experts
    • Explaining Case Management to Members
    • Evaluating Program ROI
    • Staffing Case Management Programs
    • Case Manager Case Load
    • Transitioning Between Outreach Teams and Case Management
    • Embedding Teams in Primary Care Practices
    • Compiling an Outreach Effort Spreadsheet
    • Staffing a Transitional Team
    • Optimum Patient Management
    • Adult Day Services
    • Patient Costs
    • Case Manager Skill Sets
    • Role of Home Health
    • Nurse-to-PCP Ratios
    • Medication Reconciliation
    • Patient Monitoring
    • Patients Plan of Care
    • Advanced Illness Program
    • Support Staff Requirements
    • Fitting Case Management Into the Medical Home
    • Engaging Non-Compliant Patients
    • Prioritizing Patients in the ED
    • When the MD Wants to Discharge
    • Essential Skills of the ED Case Manager
    • Evaluating an Embedded ED Case Management Program
    • Reducing Heart Failure Readmissions
    • Future of ED Case Management
    • Creating Support for the Embedded ED Case Manager
  • Glossary
  • For More Information
  • About the Presenters
Publication Date: April 2011
Number of Pages: 60
ISBN 10: 1-936186-70-5 (Print version); 1-936186-71-3 (PDF version)
ISBN 13: 978-1-936186-70-9 (Print version); 978-1-936186-71-6 (PDF version)
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