Care manager to the rescue.

The key to successful 'gatekeeper' relationships

THE DEVELOPMENT OF A CARE MANAGEMENT PROGRAM HAS become essential as postacute providers grapple with the increased financial risk brought on by PPS and managed care. Care management has its roots in the flagging of high-cost outliers by indemnity and workers' compensation insurers. Once HMOs appeared on the scene, utilization management and case management became synonymous with rationing of care. For long term care providers, this meant demands for weekly reports, authorizations, verification of benefits and eligibility, justifications, and denials of lengthy stays and unlimited rehabilitation services.

Now that PPS has passed some of the financial risk to postacute providers themselves, even more astute care management is required.

Care management is a collaborative process involving assessment, planning, implementation, coordination, monitoring, and evaluation to ensure the provision of high-quality, cost-effective services and outcomes. The care manager acts as liaison between patient, provider, and payor. The care manager must be objective, having no vested interest in any one particular discipline, and must be resourceful in developing medically appropriate options and alternatives to costly and unnecessary services.

The care manager must be an advocate for patient-entitled benefits and be familiar with disease processes, available resources, and treatment modalities. An effective care management program also includes cost-tracking and marketing components.

A care manager's first goal--achieving measurable quality patient outcomes--requires developing a database and a collection of outcomes measurement tools that record average length of stay by payor type and by top five major diagnoses, discharge data, and three- and six-month discharge follow-up. The care manager should monitor quality by implementing an on-site patient assessment program, collecting and reporting outcomes monthly, setting up standing meetings with the rehab department to monitor utilization, and participating in weekly interdisciplinary meetings to ensure medically appropriate utilization of services. The care manager should also educate personnel on the principles of PPS and managed care and assist in the development of critical/clinical pathways.

But almost as important is continuous monitoring of the profitability of Medicare and managed care residents. The first order of business: implementing a revenue- and cost-tracking worksheet. The care manager should report monthly on profit-and-loss trends and managed care contract utilization and assist in managing the patient account system with an eye toward improving billing and accounts receivable.

The care manager must work with payor sources to verify benefits and eligibility and to determine requirements for claims processing. In addition, the care manager should be capable of exploring solutions to coverage limitations, negotiating extra-contractual coverage, and flexing benefits to cover any unusual and/or high-cost services. Also, he or she must have expertise in developing and implementing cost-containment strategies, overseeing contractual agreements to ensure that services don't exceed the allowable reimbursement.

The care manager should contribute to the achievement of an integrated health care delivery model by, for example, assisting in the development of physician partnerships and other strategic alliances, and play a part in community outreach by educating referral and payor sources as to the clinical and financial advantages of postacute care and promoting the facility's Medicare, subacute, and managed care programs.

Before hiring a care manager, determine whether the addition of this position is justifiable from a financial standpoint. Keep in mind such things as patient acuity and expected Medicare and managed care census. Determine future trends, relationships, competition, and population shifts that could impact census. To justify a full-time care manager, your minimum daily census of at-risk residents should be from 6 to 10, depending upon factors such as your acuity levels and payor mix, Otherwise, consider sharing a care manager with another facility or combining the role of care manager with, say, your admissions coordinator or marketing director. But don't combine this role with a staff nursing position due to the frequent need for meetings and off-site assessments.

Develop clear expectations, roles, responsibilities, and qualifications for the care manager. Too often, the role of care manager is poorly defined, leading to disappointment on the part of both employer and employee. Especially because the care manager's role extends to all departments, there is a need for clearly defined qualifications, responsibilities, and expectations. I have seen the abilities of a care manager severely compromised because department heads either don't understand what can be expected of the position or have unreasonable expectations.

Jeffrey L. Stuckhardt is president of HealthCare Strategies, a Newport Beach, California-based health care consulting company specializing in postacute care.