Case Management in Skilled Nursing: Managing Care, Cost and Outcomes

Transcription

1 Case Management in Skilled Nursing: Managing Care, Cost and Outcomes Learning Objectives Define the role and function of the Case Management Coordinator Understand how to balance Medicare and Managed Care requirements in SNF Review case management best practices from admission through discharge What is Case Management? A collaborative process of assessment, planning, facilitation, care coordination and advocacy to meet the individual s and family s comprehensive health needs and promote quality cost effective outcomes. 1

2 Case Management defined: From the context of the health plan - A method of managing the provision of health care to members with high-cost medical conditions. The goal is to coordinate care so as to both improve continuity and quality of care, and lower costs. Case Management Expectations in Skilled Nursing Assist the patient in meeting goals toward optimum function & recovery Document the care provided with relevant charting and accurate MDS assessments Accurately bill for services delivered Focus on clinically indicated quality patient care and appropriate financial outcomes will follow Case Management Coordinator: Acts as advocate and liaison between patient and all care providers Ensures that patient receives all clinically necessary services Provides daily contact to support patient satisfaction Educates patient/family to facilitate active participation in the recovery process 2

3 Case Management Coordinator: Helps patient/family understand and cope with the medical, insurance and emotional challenges of an inpatient stay Acts as point person for hospital DC planner, physician, MCO Contributes to the Care Plan regarding goals for discharge, developed with the patient and IDT Case Management Coordinator: Assists with control of costs: rehab therapy services, medications, appts with healthcare providers outside the SNF Supports accurate reimbursement, relative to patient s insurance coveragebenefits and limitations Reports to Executive Director Facilitates successful DC to community, reducing unplanned discharges Medicare vs Managed Care - Expectations & Strategies 3

4 Medicare A Qualifying hospital stay of 3 consecutive days (admission vs observation) Physician certifies skilled need Meets Medicare criteria for daily skilled need: can only be provided in a SNF, for condition treated during hospital stay Discharge goals are supported by patient s prior level of function Medicare A Medicare benefit and rehab goals focus on highest practicable level as defined by OBRA, which is why length of stay is typically longer Prospective payment (PPS), based on completion of the MDS assessment & subsequent per diem rate for patient s RUG classification Managed Care Patient s condition must meet medical necessity criteria, but may differ from CMS Insurance provider authorizes SNF placement and services Managed care contracts vary in what is considered covered service Goal is safe discharge to lower level of care vs achievement of PLOF 4

5 Managed Care Case Manager communicates with MCO upon admit to confirm contract, coverage, billing conditions, authorized services Concurrent review- services reviewed by MCO as they are provided Changes of condition/treatment that impact Level of Care (therapy, meds) require timely request for new authorization Managed Care Facility Case Manager provides written authorization to Therapy re: days & minutes of service, based on MCO contract & authorized Level of Care Coverage typically approved by MCO for Therapy, less often for skilled nursing only Med Advantage (Medicare replacement) plans require NOMNC & patient right to appeal as does Medicare Case Management Best Practices- Functions & Tasks 5

6 Case Manager Functions: 1) Meet all newly admitted skilled patients 2) Review medical record: diagnoses, H&P, skilled needs, medications 3) With Business Office, confirm qualifying stay (if Medicare A), verify payor source (CWF, C-SNAP) 4) Validate compliance: consent to treat, admission orders signed and dated, Medicare A certification Case Manager Functions: 5) Collaborate with Therapy in assessing patient s safety and ability to live independently at home or other setting- Complete a comprehensive Prior Level of Function Assessment Set goals with patient and family: focus on outcomes and safe discharge vs dates PLOF Assessment When Patient Lived in Community 6

7 PLOF Assessment When Patient Lived in LTC Setting Case Manager Functions: 6) Within the first 3 days: Review the initial plan of care and discharge goal with patient & family, based on clinical status and insurance coverage Provide a written record for future reference: Wellness Plan Sets the tone for expectations, length of stay, CM as contact Medicare Wellness Plan 7

8 Insurance Wellness Plan Case Manager Functions: 7) Document updates in medical record & caseload notes for IDT reference 8) Monitor & manage ancillary costs, e.g., pharmacy, rehab, lab, x-ray, ambulance 9) Educate patient and family regarding disease and medication management Case Manager Functions: 10) Prepare patient/family for discharge or discontinuation of skilled coverage 11) Collaborate with Social Services & Therapy regarding set up of DME, home health follow up, contact with community support agencies 12) Schedule post-discharge appointment with primary physician and/or specialist 8

9 DAILY Case Management Tasks: Perform a routine check on skilled patients prior to morning IDT meeting Review medical record for updates: progress notes, new orders, lab results Attend daily stand-up meeting to report on condition changes, any customer service related concerns Communicate status changes with MCO/ physician group, external case managers WEEKLY Case Management Tasks: Weekly IDT Meeting: review of skilled patients Medicare A & B, Med Advantage, Insurance Monitor therapy utilization, consolidated billing conditions Caseload review call with District Director of Case Management Review operational reports- key metrics WEEKLY Case Management Tasks: Communicate updates to managed care partners for Concurrent Review Contact families to discuss updates or changes in plan of care Collaborate with IDT in development and implementation of plans related to performance improvement goals 9

10 MONTHLY Case Mgmt Tasks: Review pharmacy invoice for high cost medications & potential exclusions Review Therapy invoice Assist the Business Office prior to the release of Medicare claims- sequence diagnosis/icd-9 codes for billing validate regulatory compliance review potential consolidated billing issues Case Mgmt Opportunities Payor source verification duplicate review Audit nursing notes to ensure skilled charting- nursing skills all patients on Medicare Regular meetings with ED to review clinical and operational goals, performance improvement plan Case Mgmt Opportunities Collaborative patient/family education between nursing and therapy Thorough clinical review of conditions that qualify patient for continued Medicare coverage under skilled nursing, after therapy discontinued Discharge planning from day of admission 10

11 Karen Eils District Director of Case Management Nursing Center Division Kindred Healthcare 11