Case Management: Is Your Organization Positioned to Design and Implement the Future Care Management Model?

In this edition of IMA Insights, we explore ways in which healthcare leaders can determine if their case management leadership, organizational structure, and processes are effective and aligned for future challenges across the continuum of care.
Case Management within the acute care environment has experienced challenges in leadership effectiveness, coordination of care, collaboration and teamwork, communication, data collection and analysis, reimbursement, outcomes reporting, and compliance with regulatory entities. The need for continuous adaptation to changing patient care needs, regulatory requirements, diverse roles and responsibilities, and outcomes reporting has contributed to numerous operational issues. Critical to the success of Case Management is the appointment of leaders who are adept at responding to an ever-changing environment.

Traditional case management assists with determining appropriate patient placement, influencing length of stay, and assuming tasks that affect reimbursement such as denial management and utilization review. The responsibilities have evolved to include (in varying degrees) accountability for social work, patient throughput, core measures, readmissions, patient satisfaction, implementation of evidence based practices, reporting of compliance measures linked to the Code of Federal Regulations (i.e., Important Message from Medicare letters, Condition Code 44), Utilization Review Committees, as well as denials and appeals management.

When compared to other departments, Case Management is the only department that has a broad scope of responsibility with deep penetration across functions and line authority. The need to interface directly with finance, clinical departments, medical staff, health information management, admissions, community resources, and insurers has resulted in various reporting structures. The most prominent reporting structures align the department with the Chief Financial Officer, the Chief Nursing Officer, and the Chief Medical Officer. Some healthcare systems have incorporated a senior administrative position for Case Management reporting directly to the Chief Executive Officer in an effort to address future continuum of care needs.

Organizations successful in case management show the ability to:

Attract leadership talent with strong knowledge of case management and solid experience as change agents
Make cost conscious decisions based upon reliable data, systems thinking, and process knowledge
Invest in education and technology
Implement a reporting structure that supports authority to make decisions across departmental lines
Design processes that are hardwired for predictability
Hold people accountable for meeting quality and financial outcomes
Respond with a call to action when change is required
Manage teams across functional lines
Build trusting relationships and partnerships with medical staff

Although the historical focus of Case Management has been to reduce and control expenses while improving the quality of care for patients, this goal has not effectively translated into all provider environments. Compounding the operational challenges are external factors such as regulatory oversight by entities such as Medicare Recovery Audit Contractor (RAC), as well as reporting of quality measures such as Hospital Consumer Assessment of Health Providers (HCAHPS) and core measures that will determine the reimbursement for services provided to Medicare patients.

The evolving healthcare delivery system requires care management leaders who are designing and testing care models for the future and demonstrating the aforementioned abilities. Organizations that have mastered the leadership requirements are ahead of the curve and prepared to design future state Case Management models.
First, leaders face the challenge of critically and objectively assessing their Case Management leadership structure and taking action to provide the necessary skills, abilities, and environment for success in the future. Assuring the appropriate leadership to advance processes and practices, build external partnerships, and promote models of care is fundamental to the success of an organization's Case Management program.

Second, leaders must develop a strategic plan to assure the care of patients deploys an integrated systems approach, includes a collaborative practice model, assures effective communications, is built upon partnerships between providers and patients, and forecasts future state reimbursement models across the continuum of care.

Third, leaders must design Case Management staffing models with qualified, competent staff with relevant Case Management knowledge and experience. Staff must be articulate and responsive to the dynamic needs of patients with a focus on processes, as well as quality and financial outcomes.

Fourth, leaders must invest in the information technology systems including clinical information systems and revenue cycle systems from patient access and health information management to patient accounting and collections to improve data integrity and efficiency for care delivery, documentation, and reimbursement.

Organizational reporting structure is crucial to empower leaders with the necessary authority to bring about change. While most organizations have consolidated all responsibilities for Case Management functions under one leader, some have not. When they have not, the potential exists for conflict, inconsistency in communication and direction, variation in improvement strategies, sub-optimization of costly resources, and disjointed care delivery models.

Aligning the Director of Case Management in a direct reporting relationship to a senior administrator enables a common vision and cultivates objectives across the organization. Senior administrative positions for Care Management are emerging at the corporate level to standardize case management processes across the acute care environment and create care models that span across the continuum of care, i.e. chronic disease management. In addition, such roles are responsible for nurturing a culture focused on continuity of care, low cost structures, innovation, and exceptional clinical outcomes. This role works in a collaborative relationship with hospital based services, community resources, physician practices, insurers, and so forth.

Breaking down communication and territorial barriers between departments and disciplines is vital for Case Management to work across lines of authority. Building a team environment where all staff is accountable for cost and quality outcomes is essential. Transparency in sharing data and monitoring outcomes based upon a well-defined scorecard is a critical step to a culture of accountability. Case Management and care models of the future depend upon effective leadership, accountability-based practice models, and accessible information that is valid and reliable.

Investing in information technology that spans the revenue cycle from patient access and health information management (HIM) to patient accounting and collections improves data integrity and efficiency for Case Management. Many of these same information platforms are essential to build care across the continuum, and to capture and manage financial performance related to care management.

Leaders with the requisite skill sets to lead change, deploy systems thinking, and promote quality of care and customer service will position organizations for the future state of Case Management.

Acute care organizations with successful Case Management programs have the leaders, knowledge, skills, staff, and technology to address the challenges of care delivery models across the continuum of care.
We are pleased to have the opportunity to present this information to you. If you have any questions or need assistance, please call me at IMA Consulting at (484) 840-1984.

Best Regards,

Ilah Stolz, RN, MS