Case management: a key role.

Post-acute care is experiencing an economic metamorphosis and, as a result, those involved will be re-evaluating and possibly redefining their roles. One group of professionals who play a vital role in post-acute care - and who will be affected by these changes - are case managers. They have a variety of responsibilities throughout the course of a patient's illness or injury.

The definition approved by the Case Management Society of America is as follows: "Case management is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual's health needs through communication and available resources to promote quality, cost-effective outcomes."

The case manager can be found in any number of settings including hospitals, skilled nursing facilities (SNFs), assisted living, independent case management practice, outpatient, day-care, rehabilitation programs, physician practices, health plans, workers' comp and managed care organizations. It is not uncommon to find a case manager from the healthcare setting and one from the payer site working together to meet the patient's needs. The rehabilitation arena has long been a user of case management. As post-acute care moves toward providing more rehabilitation services in SNFs and residential programs, such as assisted living communities, case management will become more and more prevalent.

Assessment, evaluation, monitoring and coordinating services will be seen as critical as the reimbursement methodologies multiply. A perfect example is the Balanced Budget Act, which introduces the Prospective Payment System (PPS) for long-term care. This system has a number of implications for SNFs, rehabilitation and residential facilities that utilize home health care and vendors of ancillary goods and services. For instance, the SNF will be identifying Medicare recipients based on acuity levels, and reimbursement will follow accordingly. This will require training and education for the treatment team and also a skilled professional experienced in coordinating and monitoring services. The PPS coupled with long-term care's entry into the managed care market will prompt providers to identify case management as a crucial entity.

A lesson can be learned from acute rehabilitation in that when prospective payment was introduced some years back, acute rehabilitation units found case management to be an effective tool in providing more efficient services.

To further explore this topic, I enlisted the expertise of Maureen Barry, a certified case manager and a senior consultant for Ernst & Young, New York City, along with Patrick Flannery, MBA, OTR/L, administrative director of physical medicine and rehabilitation for St. Rita's Medical Center, Lima, Ohio:

Hyatt: "How does case management interact with areas of postacute care, such as rehabilitation?"

Barry: "Hospital case managers and payer case managers should identify post-acute care discharge needs upon admission or when there is a change in the patient's condition during the hospital stay. It is essential that these case managers are aware of the various levels of post-acute care programs offered at each level of care, including acute rehabilitation, skilled/subacute care, home health care, hospice and outpatient services. Providers of these services should assume the role of educators for case managers by offering in-service education programs or seminars on new techniques, equipment or programs they currently offer."

Flannery: "Case managers from the acute care hospital make contact with post-acute care case managers at the point where patients differ from the clinical pathways. Post-acute care personnel continue to assess in conjunction with the acute care case manager until a decision is made to admit to postacute care. Since the disease process is stable at this point, the acute care hospital case managers discontinue following the patient and the post-acute care case manager takes over. The post-acute care case manager acts as a liaison, advocating for the person served and monitoring outcomes and program costs throughout the length of stay."

Hyatt: "What will be the economic impact of the PPS on case management?"

Barry: "With the emphasis on providing health care in a cost-effective manner, some acute hospitalizations are being averted - or patients are discharged early to an alternative level of care. The patient should be provided with a post-acute care program that offers him/her the medically necessary services and does not compromise the quality of care received. The current economics dictate that case managers be aware of what is available in the post-acute continuum of care and be knowledgeable of the current reimbursement policies, such as case rates or capitated arrangements that the payer may have with the referring hospital. It may be advantageous to the patient and more profitable to the provider to move the patient who has undergone a total hip replacement, for example, to a post-acute care setting earlier rather than have that patient remain in the acute care setting for a longer period of time."

Flannery: "Because TEFRA and cost reimbursement will essentially disappear in the next few years, it will become more important for post-acute providers to monitor length of stay and design programming based on acuity and individual needs. The rehabilitation case manager will be key in monitoring clinical progress and weighing it against the costs. The case manager will challenge the rehabilitation team to move the patients into the most effective level of care in the most timely fashion."

Hyatt: "What are some of the barriers to coordinating services, and what might be helpful toward eliminating those barriers?"

Barry: "There can be barriers in many areas of coordinating post-acute care services for the patient. Appropriate services may not be available in all areas of the country, especially rural areas. Providers may say they have a stroke program but may only treat a minimum number of stroke patients per year. The patient may have a limited number of reimbursable days in a post-acute care facility or a limited number of home health care visits that are available and covered by insurance. Also, the patient's family may refuse a recommended provider if the location poses transportation or geographical location problems. Therefore, education of the interdisciplinary team, family and patients regarding the availability and types of post-acute care services would be most beneficial in determining a post-hospitalization plan of care."

Flannery: "The insurance industry still does not have a good system for tying benefits to certification, which requires the facility or program case manager to make multiple calls and often interact with more than one individual. An afternoon referral may have a delayed admission to the program until the next day, due to the case manager's inability to make contact with the right people in order to get verification and approval for admission, treatment, length of stay and payment information. This barrier could be eliminated by the payers' instituting a national standardization system of verification and approval for treatment."

Astute post-acute care providers will be adding case management to their service repertoire if they haven't done so already. These professionals will focus on the process of the persons served and be part of the proactive strategy that transitions patients through the healthcare continuum effectively. The future is upon us, and it is incumbent upon providers to do what is best for the patient and their organizations.

I would like to express my appreciation to all those who continue to support and participate in this column. If your organization has developed an innovative approach to the challenges of post-acute care, please forward them along with your name, the name of the organization, address and phone number to Laura Hyatt, Hyatt Associates, 2956 Kelton, Los Angeles, CA 90064.