EXECUTIVE SUMMARY

Although the ideal contemporary model uses a triad model, there’s simply not a perfect method for every hospital. That’s why case management leaders should look at what makes the most sense — dyad or triad — and analyze how the different approaches could affect denials.

• Focus on the communication flow throughout the hospital and find ways to maintain the sense of urgency that utilization management demands.

• Evaluate three to five key outcomes that affect denials on a regular basis. Analyze how the results affect denials, and make sure to share that information.

• Pilot test different models, perhaps focusing on different areas or floors, to see which approach works best.


What’s the best structure for case management models — dyad or triad? While everyone wants the magic answer, there’s no one-size-fits-all approach.

As hospital case management models continue to evolve, some hospitals continue to use the blended, or dyad, model, where case managers perform all functions.

Proponents of a triad case management model say that it’s more efficient for a case manager to handle care coordination and discharge planning — if they have a small enough caseload.

Beverly Cunningham, MS, RN, ACM, a partner and consultant with Case Management Concepts, says the ideal contemporary model is a triad model, with the functions of utilization management, discharge planning, and care coordination.

“The ideal case management process is not to silo case management functions. This is often found in the dyad model,” Cunningham says. “There are so many things to consider when selecting the best model. Understanding why hospitals transition from a triad model to a dyad model is incredibly important. There might be a need, but I would think this is rare, for a dyad model in the situation of very challenging payers.”

However, she notes that this often can be eliminated by having a very strong appeals process in the case management department that works with staff, physicians, payer contracting, and payer relations.

The biggest thing to take into account is the communication flow throughout the hospital.

“That really is where the dyad model — where UM [utilization management] is often separate — can set the scene for siloed communication. It also sets the scene to diminish a sense of urgency. Effective utilization management is an urgent process; it’s a priority that must be done,” says Cunningham.

For example, what is the case manager at the bedside witnessing overall? What is he or she hearing from team members (e.g., a physical therapist or a dietician) and from the physician?

“If you’re an RN case manager on the floor, you just talk to the doctor. When you silo that role out, you lose that opportunity for complete and timely communication. That’s a challenge,” notes Cunningham.

Five Strategies to Implement

The following are five key points to consider when choosing a model:

1. Understand your payer needs.

With either the dyad or triad model, there should be strong understanding of payer needs and requirements, physician advisor roles, etc. For example, larger urban areas typically have more payers, more commercial plans, and more Medicare/Medicaid plans.

Take a step back to see all the driving forces:

• Is there an accountable care organization?

• Is there a patient-centered medical home?

• Does the continuum include bundled payment patients?

• What providers in the continuum are owned by the hospital — such as home health, hospice, acute rehab, inpatient psych, outpatient psych, physician offices, and skilled nursing facility?

2. Know your processes.

Use a flowchart to help decide what’s best at your hospital, particularly when it comes to ensuring seamless communication for everyone on the medical team.

“If there’s a really good electronic case management program, you have to educate the case manager on the floor about their responsibility. Do they, or can they, watch their computer to see what’s going on?” asks Cunningham.

In the case of remote case managers, figure out who’s going to call the doctor and document the process. But if it’s the onsite nurse case manager who needs to call the doctor, then document that process, too.

Another idea is to perform a pilot test and see which works best. The results could be surprising and show that what worked on one floor (e.g., medical/surgical) didn’t quite work on another.

3. Educate everyone to the ideal processes.

Not many case management departments have an educator, but some do.

“That’s a key role in a case management department,” says Cunningham. “They can maybe do a small class and then individually mentor staff. Maybe you have team leads or managers or people who really understand the process and can help staff. Small group education and mentoring on the floor is important.”

But if teams include offsite utilization review, consider webinars and similar video conferencing tools for ongoing education that would appeal to everyone, regardless of location.

Whether onsite or online, remember to look at the processes involved in ongoing education and share the results. Communication is key in ongoing education.

4. Evaluate the outcomes.

Identify a few key outcomes that may affect denials.

“Often, the initial switch to offsite utilization review was due to too many denials, so identify areas that need improvement and what can be fixed,” says Cunningham.

But don’t collect so much data that people don’t know what to do, she warns.

“Pick just a few things to evaluate on a week-by-week basis, such as denials or feedback from physicians as a process outcome. After 30, 60, and 90 days, analyze the results on denials, and make sure to share that information,” she says.

5. Improve on any gaps.

Finally, remember to mind the gap — use the newly collected data to fix any issues.

If physicians are complaining about too many calls, what can be done about that? For example, do the doctors prefer texts to a phone call?

Another example is the remote utilization review (UR) nurse who needs to contact a physician or nurse case manager because the patient isn’t meeting medical necessity.

“A sample goal is the UR nurse would have a response within an hour. That’s one of your process measures — do they have a response within an hour from the case manager or physician?” Cunningham asks. “The data may show that it took more than an hour. If you’re constantly having delays, then that interferes with the sense of urgency.”

If the delays are only with one unit or only with one physician, then delve into the data to identify gaps and strategies for total process improvement.

“Let’s say you have five gaps — pick the most important or pick the one that’s the most low-hanging fruit and take care of that, and then move on to the next one,” she adds.