Medical Management Guide, 2009, Version 3.0 - Tricare

Page 78Case Management Version 3.0Medical Management GuideESTABLISHING A CASE MANAGEMENTPROGRAMOrganizational FrameworkThere are multiple types of organizationalstructure for CM program assignmentin inpatient or ambulatory care facilities.Integrating all case managers within one designateddepartment or cost center before assigning themto individual duty throughout the inpatient andoutpatient areas is just one model that may add valueto the CM program. Hospital or facility size, availableservices, resources, and staff qualifications oftendetermine the program’s structure.The organizational structure of a CM program shouldabove all serve to support the practice of quality care.This includes ensuring there are a sufficient numberof:• Qualified case managers to service the population(see The Case Management Professional, laterin this section).• Data management systems to meetdocumentation and data mining requirements.• Support staff to assist the case managers in theirclinical management of patients.The program should also support national CMstandards of practice and encourage CM certification.Access to physician consultation, benefits advisors,decision support criteria (e.g., McKesson ® InterQual ®evidence-based clinical support criteria, MillimanCare Guidelines ® — see Section II, UtilizationManagement), decision support staff, andeducational resources are essential.GoalsMHS CM program goals include:• Establishing processes to proactively identifywounded, ill, or injured Service members whomeet the criteria for assignment to clinical CMas determined by Directive-Type Memorandum(DTM) 08-033, Interim Guidance for ClinicalCase Management for the Wounded, Ill, andInjured Service Members in the Military HealthSystem (Draft) —http://www.dtic.mil/whs/directives/corres/dir3.html. (See also CD-ROMResource CM-21.)• Creating and implementing comprehensiveperformance measures to facilitate appropriateand successful execution of clinical CM, asoutlined in DTM 08-033.• Establishing processes that will be used toimprove care as patients and their familiestransition along the continuum of care, ensuringseamless hand-off during transitions of care(TOCs) — see Transition/Coordination ofCare, Transition of Care, later in this section.• Establishing processes to proactively identifyother patients who meet the criteria for CM.• Ensuring services are rendered in a timely andcost-effective manner without compromisingquality of care.• Assisting patients in maintaining the maximumamount of autonomy and human dignity whilehelping minimize the impact of long-termchanges in living and occupational status, as wellas disability level.To successfully administer CM services, the MTFmust establish processes critical to the program. ACM program must target the right population for