Discharge Planning Advisor-Case management core not about different models

When the Center for Case Management in South Natick, MA, began hospital-based case management in 1986, the health care system was more stable, as was the definition of case management, says Karen Zander, RN, MS, CS, FAAN, principal and co-owner.

Back then, she adds, case management could be defined simply as "a clinical system in which an individual or group is accountable for coordinating patient care across a continuum or episode."

In today's health care environment, Zander says, it seems that everyone is pushing a different case management model, and everyone is sure that theirs is best. After fielding more and more requests for descriptions of the various models and for her opinion on the pros and cons of each, Zander says she became convinced that something different was called for.

"Rather than comparing and contrasting the models, what was needed was a framework for decision-making based on where an organization was at risk financially and clinically," Zander contends. In an attempt to make sense of the diversity of the various models, she has developed a decision making tool based on what she terms "The Evolving Core of Case Management Roles." (See illustration, above.)

The resulting framework shows a four-step evolution, which Zander explains as follows:

1. Acute care. At this level, utilization review and discharge planning are no longer separate. Both roles are merged into case management in an attempt to control resource use related to such factors as physicians' orders and discharge planning. The concern is with levels of care (regular patient floor vs. intensive care unit). It is matching resources to reimbursement. However, the question is, Zander points out, "Should you design a whole infrastructure around this singular need to get them in and get them out?"

2. Episode. Medicare drove case management to this level, Zander notes. That is, a discrete episode of care was the new level of risk. The financial risk is that there is no reimbursement for extended length of stay while the clinical risk is a lack of coordinated, consistent care, which may compromise outcomes. This is the level where clinical pathways become useful and case managers are often assigned to manage them.

3. Continuum/integrated health systems. This level of risk involves more managed care contracting and, in anticipation of eventual capitation, the need for control over the environment beyond the acute care hospital. At this point, hospitals and other levels of care are merging or affiliating into integrated health systems. Typically, there is little continuity from one facility to another and it is not the pathway patients who are the issue. Rather, it is the complex patients who need management of their transitions to the various levels of care.

This creates a need for a combined episode-continuum infrastructure and calls for more clinical case management than clerical case management. However, Zander points out, this management represents an investment rather than a true cost savings.

4. Physician practice/community. Capi-tation begins to be implemented at this level and panels of patients must be case-managed, primarily through physician practices. The financial risk is to manage the per member/per month dollars so that patient care is provided at the lowest level of cost, but with the patient's quality of life and functionality remaining at the highest possible level. Ultimately, she explains, population management in the community is the goal, with case management being replaced by self-management.

With this framework in mind, Zander says, she advises health care organizations to anticipate their level of risk and to "build a case management model at least one level above where you are now." But keep in mind, she adds, that "the farther out from the acute care level you go, the more advanced practice people are needed, with higher degrees, a wider skill set, and good interpersonal skills."