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By Patrice L. Spath, ART, BA
Consultant in Health Care Quality and Resource Management
Forest Grove, OR
Mental health and chemical dependency facilities are under increasing pressure to decrease costly inpatient utilization. Third party payers are not only questioning the efficacy of hospitalization, but many insurance plans limit inpatient benefits so severely that patients’ fears of out-of-pocket expenses result in early discharge due to patient request. Now, more than ever, case management programs in mental health and chemical dependency facilities must be strengthened. Case managers must help caregivers decrease inpatient expenditures to prevent unwarranted depletion of a patient’s insurance benefits. In addition, case managers must be prepared to respond to the data requests made by external reviewers. Both priorities are critical to the financial success of the hospital.
The hospital’s case management program should employ a multidisciplinary approach for decreasing overutilization and identifying underutilization. Many facilities examine utilization issues at the weekly treatment team conferences, with case management staff present to lead the discussions. Using data gathered from their concurrent review process, case managers should provide the team with information about potential overutilization or underutilization situations. Examples of overutilization include:
• On admission the patient has no acute symptoms/unstable condition, and the patient is manageable at a lesser level of care.
• The inpatient admission is used as a substitute for incarceration in a penal institution.
• The inpatient admission is used for the primary symptom of deviant (adolescent) behavior which has necessitated previous hospitalizations where environment control is the primary focus of treatment.
• The inpatient admission is used because of family wishes, despite the symptoms.
Treatment issues include the following:
• After the patient has reached maximum benefits, he or she is unable to be placed outside the facility because of family dysfunction, placement problems, or inadequate discharge planning.
• Management is primarily directed at bringing about characterological changes or alterations in the family situation, which could be more appropriate to long-term care.
• The patient is receiving unnecessary tests and procedures.
• The patient is receiving treatment for symptoms which are not acute and could be treated in a lesser level of care.
• The patient’s type or dosage of medication hasn’t changed for "X" number of days.
• The patient has received more than X number days of inpatient treatment for alcohol rehabilitation.
• The maintenance on most restrictive environment is X number of days after admission, and the patient doesn’t exhibit homicidal/suicidal tendencies or elopement or combative behavior, and a restraining order has been achieved.
• The patient is able to perform activities of daily living and function in a nonhospital setting.
Treatment failures occur in these situations:
• There is a failure to improve after X number of days of treatment.
• There is a failure to comply with treatment program after X number of days.
Discharge planning problems include the following:
• There is no specific follow-up treatment plan established.
• The patient isn’t expected to return home, his or her discharge is pending, and there is no investigation into alternative residential facilities, partial care programs, or community housing.
Some common examples of underutilization include:
• Assessments are required or necessary but not ordered or completed.
• Assessment isn’t used in planning appropriate treatment for patients.
Problems with the treatment plan include not addressing in measurable terms the objectives related to problems requiring inpatient treatment. In addition, revisions haven’t been made in response to the patient’s change in clinical status.
With clinical care, the treatment being provided to the inpatient may not be skilled in nature. Response to treatment may not have been summarized on a consistent basis. Discharge planning may be absent or inadequate. The patient may be planned for discharge with changes in drug dosages to be continued, and there may be lack of evidence of stabilization of the medication regimen.
During concurrent review, the case management staff should also gather data on the adequacy of record documentation, which is so critical to justifying patients’ need for hospitalization. The case management worksheet provides space to record the results of chart review and the actions taken when documentation was inadequate. (See worksheet, p. 190.) Summaries of this review should regularly be reported at the weekly treatment planning team meetings.
The second aspect of an effective case management program is conscientious reporting of patient information to external review groups. This requires an appreciation of the types of clinical data required by third party payers during their off-site review processes. To help case managers to efficiently collect and report the minimal amount of information, develop guidelines as to what data should be captured from the record, such as the admission/continued stay guidelines for patient data release. These guidelines are based on the questions most commonly asked by health plan case managers inquiring about an inpatient undergoing alcohol dependency treatment. Similar guidelines can be produced for other types of patient treatment.
Case managers in mental health and alcohol/chemical dependency treatment programs are being challenged by today’s health care economics and the dwindling number of patients with health plans that adequately cover mental health/dependency treatment. These three issues remain paramount:
• Ensure that patients’ inpatient benefits are not unnecessary depleted.
• Provide information to caregivers to help them identify improvement opportunities (patient care and record documentation issues).
• Furnish sufficient information to health plan case managers to minimize unnecessary payment denials.