Rehabilitation case management: what to expect.

This should have been an easy column for me to write - after all, case management was virtually born out of the rehabilitation arena. As a certified case manager, I interviewed other case managers. After a short time, though, it became apparent that this was going to be anything but easy. This was partly because of the variety of case management settings. To present an overall view that might be useful to facilities considering case management under PPS, I spoke with case managers who represent a myriad of locations, including independent, payer-based and facility-based. I asked all of them to discuss best practices in rehabilitation case management.

Case management and its impact on patient care are evolving. Some uncertainties remain, but many of the experts predict that more data quantifying case management activities will lead to a clearer understanding of the field's best practices. Reimbursement, too, will play a significant role in shaping case management. Enough experience has accumulated, though, to provide a sound idea of what to expect from this relatively new healthcare specialty.

I would like to thank the experts who participated in this column, and invite you to send your ideas about this or future columns to Laura Hyatt, Principal, Hyatt Associates, 2956 Kelton Avenue, Los Angeles, CA 90064. Please include your name, name of your organization, address, area code and phone number in order to receive a response.

Eileen T. Chiama, RN, MS, FACMPE, Principal, Greenwich Healthcare Consulting in Trabuco Canyon, CA, responded, "First, the case manager should clarify the case management action in medical terms, including proper coding if applicable. When the payer looks at reimbursement, the coding becomes a critical issue. It is often helpful to speak with the payer to get insight into their specific coding requirements.

"Second, the case manager should determine if the payer uses standards of care or a defined set of best practices. Without such information, the case manager cannot effectively negotiate the fine points of the case for reimbursement.

"Third, the case manager should determine how the payer wants to receive information regarding the case. For instance, telephone communication might be reserved for those cases that need discussion, whereas a fax might be used if the case follows the payer's standards of care and utilization management guidelines without deviation.

"Fourth, the case manager should communicate regularly with the payer, using a single point of entry if possible. Communicating with the same person on cases will often speed the answers to important questions."

Michael J. Demoratz, LCSW, CCM, Director of Business and Professional Development, CareMeridian in Orange County, CA and President-Elect of the Southern California Chapter of the Case Management Society of America, suggests, "Best practices have to include goal-directed outcomes. Returning an individual to gainful employment or active retirement, or achieving an overall reduction in costs of medical care, can benefit us all. Goals must be reasonable and attainable. For example, someone with a complete C1 spinal injury is unlikely to walk again and should not have unrealistic goals set. It is vital to the patient's and the family's adjustment that they begin to understand and comprehend their life-altering circumstances, because the family's support and ours can go a long way in enhancing the patient's recovery process. However, the process of goal development in rehabilitation is not static but ongoing. Input from patients, their families and the treatment team will constantly readjust their goals to set the bar to reasonably higher levels."

Roberta M. Suber, Los Angeles Director, Health Solutions' Virtually integrated Health Management System (VIHMS) in Burbank, CA, noted, "The VIHMS Project is a clinical model and software program designed to aid in case management and coordinate elements of the healthcare system. UniHealth, a California-based managed care company, was initially engaged to design and test the system with funding from Monsanto's Health Solutions Division. The application logically builds links between each individual's member characteristics, medical events, pharmacy data, lab data, claims data and provider referral information. In response to triggers from these links, sets of interventions grouped into standard operating procedures have been created to facilitate care coordination. The model recognizes that certain member characteristics are associated with an increased risk of problems as a result of poorly coordinated care. Through the identification of these characteristics, the care coordination model selectively targets those individuals who are most at risk of experiencing costly medical events, thereby taking a preventive or proactive approach. A coordination specialist - a registered nurse or licensed clinical social worker with specialized training and experience implements interventions."

Andria W. Jacobs, RN, MS, CEN, CPHQ, Administrative Director for Medical Management for VertiHealth Administrators in Chatsworth, CA, explains, "For the case manager, care planning and the best orchestration of services begins with an interview of the patient and/or family. This global assessment determines both the immediate and long-term goals for the patient and the family's ability to be supportive. My colleagues and I use a multi-disciplinary approach, working with the attending physicians, the facility case manager, social worker and discharge planner. The patient's progress in the care setting is monitored and the patient's capability to participate in rehabilitation is determined.

"One of the issues we have frequently confronted involves patients who want to enter acute rehabilitation but are not physically or mentally ready for the intensive therapies that are an integral part of this program. Patient and family meetings with the rehabilitation staff are scheduled to develop a mutual understanding of what is required to participate. As it turns out, some patients are better served by a period of less intensive but continuing therapies until they can progress to an acute rehabilitation setting. In general, fewer rehabilitation failures occur when patients and their families are ready for the rigors of therapy."