Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 58Case Management Version 3.0Medical Management GuideThe MHS has established wounded, ill, and injured(sometimes referred to as WII) Service memberrequirements, which provide a unique level ofintensive CM services for Active Duty Servicemembers (ADSMs) with complex medical needsserving in the Army, Navy, Air Force, Coast Guard,and Reserve components.Management (DM), which is based on populations(see Section IV, Disease Management). Onesignificant aspect of CM is care for patients withspecial needs, which may be physical, behavioral,emotional, or educational in nature and may requireintense coordination and collaboration amonghealthcare team members.Definition, Goals, and PurposeThe TRICARE Management Activity (TMA) utilizesthe definition of CM employed by the CaseManagement Society of America (CMSA, 2002),as follows: A collaborative process of assessment,planning, facilitation, and advocacy for optionsand services to meet an individual’s health needsthrough communication and available resources topromote quality cost-effective outcomes. (See alsoAppendix C, Definitions.)Military case managers have adopted the CMSA’sdefinition of CM but broadened its application byplacing CM under the Population Health continuum(see Fig. 12, above). CM services, which are focusedon the individual patient, may overlap with Disease“Complex CM” may be delivered to patientswith chronic illness resulting from disease orcomplex injuries. The National Committee forQuality Assurance (NCQA) defines complex CMas follows: The coordination of care and servicesprovided to members who have experienced a criticalevent or diagnosis requiring the extensive use ofresources and who need help navigating the systemto facilitate appropriate delivery of care and services.The goal of complex CM is to help members regainoptimum health or improved functional capability, inthe right settings, and in a cost-effective manner. Itinvolves a comprehensive assessment of the patient’scondition; determination of available benefits andresources; and development and implementation ofa CM plan with performance goals, monitoring, andfollow-up.Case Management is acollaborative process ofassessment, planning,facilitation, and advocacy foroptions and services to meet anindividual’s health needs throughcommunication and availableresources to promote quality,cost-effective outcomes.Originally, CM almost exclusively targeted inpatientswith catastrophic illnesses or injuries. However, anumber of developments have served to change thatstrategy; notably:• The emergence of the National Committee forQuality Assurance (NCQA): http://www.ncqa.org/.• The development of accreditation standards bythe Utilization Review Accreditation Commission(URAC): http://www.urac.org.
Medical Management GuideVersion 3.0Case ManagementPage 59• The enrollment of Medicare and Medicaidpopulations in managed care plans.• New legislation mandating CM services (seeSections 1611 and 1615 of the National DefenseAuthorization Act [NDAA] of 2008 and theDoD/VA response to those recommendations,Executive Summary CD-ROM ResourcesES-3 and ES-4).While CM continues to focus on catastrophic illnessor injury, CM practices are also intensely directed ataddressing chronic conditions that are more prevalentin the general patient population. Case managerscan affect patient outcomes through proactiveinterventions across multiple healthcare settings.Additionally, case managers are expected to engagecommunity resources and facilitate ongoing andconsistent patient education.The MHS has three primary goals for CM:• Improve the care, management, and transitionof recovering Service members.• Broaden the application of CMto include beneficiaries withcomplex needs and at-riskbeneficiaries before theyrequire complex care.• Evaluate the impact of CM onthe quality and efficiency ofmilitary health care.1. CommunityResources and Policiesbetween facilities or between outpatientmedical and BH services.• Assist the recovering Service member and his/her family in understanding the recommendedtreatment (including BH services) and inreceiving timely access to that treatment.The goal for patients coping with chronic disease isself-management and patient empowerment. Whiledisease managers provide the medical care neededfor the patient’s specific disease, the hand-off tocase managers supports much-needed, ongoingholistic coping and management strategies aspatients strive to achieve optimal functioning andquality of life. Fig. 13 is a useful representation ofactivities involved in Chronic Care Management.The purpose of CM is to:• Promote quality, safe, and cost-effective care.• Promote utilization of available resources toachieve clinical and financial outcomes.• Facilitate appropriate access to care.3. Self ManagementSupport2. Health SystemHealth Care Organization4. DeliverySystemDesign5. DecisionSupport6. ClinicalInformationSystemsAdditional goals applicable to caringfor wounded warriors are to:• Assist the recovering Servicemember in receiving qualitymedical and behavioral health(BH), which may include lengthyinpatient stays and transistionsInformed,ActivatedPatientProductive InteractionsFig. 13 – Chronic Care Management ModelPrepared,ProactivePractice Team
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