What a case manager brings to the game
What a case manager brings to the game
Here’s what a case manager could do for you
Case managers can collaborate with physicians in a variety of ways, says Sue Binder, RN, CCM, principal of Integrated Healthcare Consultants in Caldwell, NJ. Here are some jobs a case manager can perform:
• Advocating for the patient.
The case manager works with the insurer to make sure patients get the treatment they need.
• Identifying alternative sources of services.
"When you have benefits that cover A and B but not C and D, you look beyond the insurer and tap into community and church resources," Binder says.
She describes her work as creating a "patchwork of reimbursement." For instance, a lot of senior citizens need custodial care, such as help with meals, light housekeeping, or personal care to live independently. Most insurers won’t cover these services. In these cases, Binder looks for Meals on Wheels, senior citizen centers, or church volunteers to fill the gap.
• Preventive care.
Case managers can set up wellness programs for your practice or plug your patients into programs that are already operating in the community.
"There’s no sense in reinventing the wheel. A lot of hospitals and community agencies are developing health awareness programs. If there’s a good program in the community, the case managers can steer patients toward that," Binder says.
• Utilization review.
At Brown-McHardy Clinic in Metairie, LA, nurse case managers precertify outpatient procedures any time a physician wants to order a diagnostic study that costs more than $350, says Kathy Calahan, RN, director of health services.
First, they make sure the patients are still eligible for coverage from their health plans. Then they check to see if the request meets criteria established either by the health plan or HCFA guidelines. If it doesn’t meet the approved criteria, the request is sent to the Utilization Management Committee, a group of 12 physicians who make the final decision and give the physician alternatives.
"We don’t have nurses denying care. If it doesn’t fit the criteria, we sent it to the UM committee," Calahan says.
• Disease management.
Case managers help patients with chronic or terminal illnesses learn to manage their diseases and avoid office visits, hospital admissions, or emergency room visits.
"Even a reduction in repeated emergency room visits can count as soft savings when you consider that the physician has to be involved every time a patient goes to the emergency room," Cadogan points out.
If you are in a capitated contract, at least a portion of the emergency department costs could come out of your pocket, she adds.
Browne-McHardy Clinic contracts with an outside disease management company to manage the care of their congestive heart failure and diabetes patients, Calahan says.
"They educate the patients on their disease and call them regularly to remind them of what to watch for," she adds.
For instance, the case managers remind congestive heart failure patients to weigh themselves and ask if they have noticed any swelling.
• Resource management.
"We want to get the patient to the right place at the right time and at the right cost," Binder says. Seeing that women get regular mammograms and come in for Pap smears and pelvic examinations is crucial.
[Editor’s note: Sue Binder can be reached at 29 Cedars Road, Caldwell, NJ 07006. Telephone: (973) 228-2301.]
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