Thinking of Separating Utilization Management and Case Management? Think Again!
By Toni Cesta, Ph.D., RN, FAAN
Case management is a malleable and easily adapted model that applies to a variety of care delivery locations and systems. These traits have enabled organizations applying the model to design and implement the model to meet their specific needs. Although case management has been used in the community setting for the longest period, it is now commonly seen as an integrated care delivery model in the acute care setting and other sites along the continuum of care (e.g., skilled nursing facilities and long-term care facilities). More and more organizations are recognizing the model’s ability to manage resources while maintaining or improving quality. Most recently, case management has been identified as a strategic tool to be used in accountable care organizations, healthcare systems, and other care delivery models that coordinate patient care across the continuum.
Since case management moved into hospitals in the mid-1980s, a variety of models have been tested and tried across the country. Variation in models usually depends on the level of integration between disciplines, roles, and functions. Each hospital thinking of changing its model must do so based on factors that affect the ability of the model to work in its organization.
The more siloed your department, the more likely that the staff will resort to tasks rather than looking at all of the elements and data associated with the patient in an integrated fashion. This is the danger associated with separating utilization review from the other roles of the case manager. This month, we will talk about the pros and cons of separating utilization management out from the role of the case manager.
As we look at the roles assumed by a hospital case manager in a model that adapts to the changes in healthcare reimbursement, value-based purchasing, readmission reduction, or care along the continuum, we quickly see how these roles are dependent on each other to work most effectively.
When siloed from each other, these roles simply become tasks rather than an integrated set of functions that are dependent on each other.
- Patient flow — clinical coordination/facilitation
- Utilization and resource management
- Denial management
- Variance tracking
- Transitional and discharge planning
- Quality management
- Core measures
- Adverse events
- Psychosocial assessments and interventions
STAGES OF MODEL DEVELOPMENT
1. Simple with no integration. These models focused on one core activity, either discharge planning or utilization management. These were the first and traditional models. They were fragmented and expensive as the discharge planning and utilization review functions were separated from each other.
2. Moderate with partial integration. These models, still in use today, focus on the core roles of case managers but typically integrate only two of the roles as listed above. They provide more of a contemporary approach to case management and are more efficient, but do not combine all of the roles of case management that are considered contemporary today. Because these models begin to integrate previously disconnected roles, they tend to be more cost-effective than the simpler models. The collaborative case management model is an example of this.
3. Complex or full integration. The fully integrated models combine all the roles of today’s case management departments as they are listed above. These models are the most forward-thinking, as they allow for fewer handoffs of information as well as more efficient use of RNs and social workers. As with all case management models, they must be combined with appropriate staffing ratios. If these models are understaffed, they will not produce the desired outcomes. The integrated case management model is an example of a fully integrated model.
MAIN DIFFERENCES BETWEEN THE MODELS
The two most commonly used models today are the integrated model and the collaborative model. There are fewer differences between these models as there are similarities. Clearly, the most effective models are those that provide a mechanism for managing patients across the continuum of care, thereby providing a seamless, integrated care process. In a managed care environment this is most easily done because of the integrated services inherent in a managed care system. The notion of managing patients in a variety of care settings is more difficult in payer systems in which there are no incentives for various settings to communicate and/or share resources. With the advent of the medical home and health home concepts, as well as the accountable care organization, Medicare has provided new incentives that reach beyond commercial payers and deeply into the government payer arena. While managed care had traditionally been viewed as the system that provided the generalized structure and focus when managing the use, cost, quality, and effectiveness of healthcare services, it is no longer the only payer interested in managing cost.
Many healthcare organizations have opted to first implement case management in the acute care setting. This accomplishes a number of things. First, it allows the organization to design, implement, and perfect its case management system in a more easily controlled environment, the hospital. Although it provides greater challenges in terms of the clinical management of patients in the acute care setting, it is still a place where team members are part of a team that is within the walls. In fact, the term “within the walls” has been used to aggregate those case management models that manage patients’ care during the acute care portion of the illness. Among the many applications of the within-the-walls models is a host of types using the members of the team in various role functions. In most cases, the RN is used as the case manager. It is the placement of the RN in the organizational structure and the associated role functions that differentiate the various models.
In the integrated model, all roles are performed by a single RN case manager. This model integrates previously disconnected roles and functions. Included in the integrated model are all the roles listed above. The nurse case manager integrates the roles of patient flow, utilization management, and discharge planning into one role that applies to all patients asigned to her. The nurse case manager is responsible for referring any psychosocially complex patients to the social worker as they are identified.
The integrated model requires that all patients are seen by a nurse case manager. For some patients that are considered “high risk,” they may also be followed by a social worker.
THE COLLABORATIVE MODEL
In this model, a third team member is added. The third member, called the Utilization/DRG Manager or business associate, is responsible for the “business” aspects of case management such as conducting clinical reviews for the purpose of transferring information to a third-party payer. They are also responsible for clinical documentation improvement. As such, the staffing ratios are different in the collaborative model. The case manager is responsible for assessing, planning, coordinating care, and outcomes management.
Each model brings pros and cons. The key differences between the two models are the integration of utilization management into the role of the case manager versus the separation of the role through the addition of a third team member. Some hospitals have separated out the functions in an attempt to lower overall costs. They accomplish this by reducing the staffing within the department of case management.
Others believe that utilization management is a “task” that can be done by anyone, either inside the hospital or in an office somewhere else. It is within this logic that the problem lies. If the organization views the role of utilization management as an isolated set of tasks or functions, then this important role becomes separated from the other roles of the case manager in a contemporary case management model.
FACTORS TO CONSIDER WHEN PICKING A MODEL
Picking a model is an individual hospital’s decision. The journey toward making this decision depends on a number of factors that need to be considered. These factors include the following:
- Model design
- Roles and functions of RN case managers and social workers
- Payer mix
- Intensity of services provided
- Complexity of patients
- Length of stay
- Product line
PRICING OUT A MODEL: GETTING THE BIGGEST BANG FOR YOUR BUCK
If your hospital is struggling with the decision of which model to pick, you may want to consider the following exercise. The purpose of the exercise is to cost out each type of model and determine which one will work best from a model perspective as well as a cost perspective. Getting started will require that you collect demographic data on your hospital and that you use this data to test out each model. The following is a format that you might want to consider when performing this exercise with your case management steering committee or executive staff. Ultimately the decision will need to be multi-factorial, but this information will give you an additional tool with which to make a determination as to which model is best for your hospital.
Case Study: Determining Case Loads and Cost of Two Case Management Models
St. Elsewhere Hospital and Medical Center Demographics
30% Managed Care
Admissions per year: 18,000
Emergency Department Visits per Year: 30,000
Patient Care Units
Specialty Occupied Beds
2 Surgical 40
2 Medical 60
2 Step-Down 20
2 ICU 30
1 Obstetrics 20
1 NICU 10
1 Pediatrics 20
Total Beds 200
Other Factors to Consider:
• Physician Advisor
• Clerical Support Staff
• Unit-Based Design/Other
Based on the hospital’s structure as described above, a staffing analysis for a contemporary case management department was created.
Social Work Assistant Director: 1
Physician Advisor: 1
Audit & Appeals: 2
Total RN Case Managers: 13
Float Case Manager: 1
Total Social Workers: 5
Clerical Support: 3
Total FTEs: 28
Clinical Areas Covered
Case Managers Caseload 1:15 (unit-based):
Emergency Department: 2
Admitting Department: 1
Social Workers Caseload: 1:17(more than one unit):
Medicine/Step Down/ICU: 2
Patients receiving CM coverage: All
Patients receiving SW coverage: 40%
Physician Advisor: Available to all staff; responds to all clinical areas
Roles and Functions of Case Managers: Patient flow, including coordination/facilitation of care; utilization management; discharge planning; variance identification; resource management.
Roles and Functions of Social Workers: Psychosocial assessments and interventions on 40% of patients meeting social work referral criteria. May perform some discharge planning.
Roles and Functions of Utilization/DRG Manager: Not applicable.
Social Work Assistant Director: 1
Physician Advisor: 1
Utilization/DRG Managers: 7
• 2 Surgical (Floors + Units)
• 2 Medical (Floors + Units)
• 1 OB/NICU/Pediatrics
• 1 Supervisor/Denials Mgmt
• 1 Relief
Case Managers: 9.5
• 1.5 ED (Days)
• 2.0 Surgical (Floors + Units)
• 3.0 Medical (Floors + Units)
• 1.0 OB/NICU
• 1.0 Pediatrics
• 1.0 Relief
Social Workers: 8
• 2.0 ED (Evenings)
• 2.0 Medicine
• 2.0 Surgery
• 1.0 OB/NICU
• 0.0 Supervisor/Pediatrics
• 1.0 Relief
Central Placement Office: 1
TOTAL FTE: 28.5
UM/DRG Management Caseload:
Adults 1:30 beds
Adult Med/Surg 1:25 (includes relief)
Note: With screening, should see caseloads of about 1:16.
Note: With screening should see about 1:14; can backup Med/Surg as needed.
Note: Can generally tolerate higher caseloads in this population.
Adult Med/Surg 1:30 (includes relief)
Peds 1:20 + Supervisor
Note: SWs cover ED during days for crisis intervention on a rotating basis.
Patients receiving CM coverage:
• Assume 50-75% post screening for medical, social, financial risk.
• Every patient needs to be managed; not every patient needs a case manager.
Patients receiving UM coverage: 100%
• Medical necessity screening
• Observation patient management
• DRG Assurance
• Denials Management
Patients receiving SW coverage: 40%
Physician Advisor: Available to all staff; responds to all clinical areas; relates to the physician community.
Roles and Functions of Case Managers: Screening; assessment/planning; continuum of care coordination; resource management; outcome management/evaluation.
Roles and Functions of Social Workers: Psychosocial assessments and interventions on 40% of patients meeting social work referral criteria; may perform some discharge planning.
Roles and Functions of Utilization/DRG Manager: Clinical reviews; clinical documentation improvement.
KEEPING YOUR MODEL PATIENT-CENTRIC
Each model requires about the same number of positions with one main difference: In the collaborative model, not every patient is seen by a case manager. In addition, the separation of utilization management from discharge planning in the collaborative model requires that there is constant and consistent communication between the case management team members so that redundancy, duplication, or missed work does not take place. This can add time and complexity to the process that does not occur in the integrated model. It also moves discharge planning and utilization apart, which can often result in these roles being performed as tasks rather than as an integrated part of all the case management needs of the patient. In addition, the social worker caseloads are much smaller in the integrated model, and because of this more patients can be seen by a social worker during their hospital stay.
It is also clear that many patients in today’s healthcare environment need psychosocial assistance while they are in the hospital as well as referrals to community resources after discharge. It is now commonly understood that psychosocial issues such as poverty, chemical and alcohol dependence, and health illiteracy can greatly contribute to readmissions and poor outcomes after discharge. These issues need to be addressed while patients are in the acute care setting and then followed up in the community. To accomplish this work, strong social work staffing ratios are needed so that social workers have the time to spend with patients, families, and family caregivers.
Case management should be designed as a fully patient-centric model with all the roles and functions of the case manager and social worker performed as part of a package of services provided to the patient, not as a series of tasks that are disjointed and performed in isolation of each other. When case management models separate these roles, they create an environment in which these roles no longer interface and no longer are applied with the patient’s current and long-term care needs in mind. Be very cautious when implementing such models and as you can see above, the argument that the collaborative model is less expensive simply does not hold true. Whenever possible, try to keep your case management roles and functions as integrated as possible for the greatest success and achievement of outcomes!
The more siloed your department, the more likely that the staff will resort to tasks rather than looking at all of the elements and data associated with the patient in an integrated fashion. This month, we will talk about the pros and cons of separating utilization management out from the role of the case manager.
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