Significance of Case Management

One of the more critical and complex departments in hospitals is the Case (Care) Management Department. Much of the reimbursement documentation, length of stay, collaborative efforts among caregivers, and other important functions related to inpatient processes lie in the domain of the Case Management Department. Typical functions performed by Case Management Departments include:

  • Access to ancillary departments in a timely fashion
  • Utilization review and denials management/clinical documentation improvement
  • Care coordination/care interventions
  • Discharge planning/care transitions
  • 30-day recovery period
  • Physician advisement (Hospitalist program - not part of Case Management, but closely tied into it)
  • Hospital leads program
  • Data management

Each case manager, working closely with the in-patient nurses, hospitalists/intensivists, clinical dieticians, social worker (usually part of the Case Management Department), pharmacist, respiratory therapist (as needed), and other members of the clinical care team, from the time the patient is admitted (even beginning in the ED), coordinates the care necessary to ensure a safe, high quality journey through the length of stay of each patient, and then follows that patient for 30 days thereafter. Ensuring that proper documentation of all aspects of the care is accounted for to ensure maximum re-imbursement is a critical role played by the case manager. In former days case management was divided into utilization review and social work. Taking a more proactive role, rather than just reviewing utilization statistics, Case Managers “lead” the charge by coordinating roles of other care givers.

In a recent Case Management project at four hospitals in Florida, the author’s consulting team spent eight on site days in each of the hospitals reviewing procedures and policies, interviewing staff, making observations, collecting data, and formulating recommendations for the staffing of a comprehensive Clinical Documentation Improvement program and expanding Case Management into the Emergency Department.

Tremendous benefits result from a well-functioning Case Management program. Length of stay is reduced, patient satisfaction increases, unnecessary utilization of resources are reduced, re-admission rates decline and revenue increases result. In the project cited, the consultants were able to identify the potential for reducing LOS by 2.62 days; accurately placing 45 percent of observation patients in inpatient or in routine post-op; avoiding readmission of patients by 5 percent, and overall generating the potential for $70 million in additional revenues over three years for the four hospitals for a net outlay of $2 million over three years. Patient satisfaction with the existing discharge process, prior to the study was 85 percent.

Adjustments in social work staffing and R.N.s resulted to better address specific workload requirements of each skill level. Benchmarking incorporated four data bases; California Benchmarks (one of the most rigorous in the industry), Florida Health System facilities, American Case Management Association and Center for Case Management guidelines. In all cases benchmarking data had to be adjusted to reflect the operations of the specific hospitals.

Management engineers and process improvement coaches would be well counseled to understand the functioning of a Case Management Department and how it affects the care delivery system of the inpatient. There are many processes which can be enhanced within in this department, benefiting the hospital, and most importantly the patient in many aspects. “It’s all about the patient!”

Frank C. Overfelt, MBA, LHIMSS, SHS Diplomate
Delta Healthcare Consulting Group