Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 80Case Management Version 3.0Medical Management Guidehealthcare services, cost savings/avoidance, andpatient/caregiver self-management.Quality measures can be applied internally orexternally. For example, an internal qualitymeasure might involve supervisor review of casedocumentation to encourage standardization.External quality control measures can be establishedby Service-specific governing bodies. For example,Navy CM at the Bureau of Medicine and Surgeryprovides documentation reviews for quality andcompliance, which helps standardize documentationpractices among Navy MTFs and medical clinics.Performing a quality review supports the concept of“best practice.” The OCMO Healthcare InnovationsProgram is an excellent source for benchmark andprocess improvements: www.tricare.mil/ocmo/innovations.cfm.CaseloadThe various responsibilities involved in MM-relatedactivities can affect the case manager's ability toprovide comprehensive services. A major factor isthe number of case managers required in an organization,which depends on the composition (casemix/acuity) of the membership. A case manager’scaseload is dependent on many concurrent factors,including:• Characteristics of the patients served.• Complexity of the plan of care.• Geographical area covered.• Amount of administrative support.• Availability of community-based services.• Experience and competency of the casemanager.• Control over funds used in the delivery of care.Caseload assignment may also be influenced by:• The clinical needs of the patient.• The psychosocial needs of the patient/family.• Cognitive challenges to the patient.• Treatment adherence issues.• The demographics of the population served.• Geographic factors.The 2008 Case Management Caseload ConceptPaper, a joint publication of the CMSA and theNational Association of Social Workers (NASW),asserts that the clinical practice setting affects thepatient-to-case-manager ratio (refer to CD-ROMResource CM-22). For example, an experienced casemanager providing telephonic CM in an outpatientsetting can manage a higher caseload than an onsitecase manager in an acute inpatient setting. Page 22of the CMSA’s concept paper features a caseloadmatrix.Specifics in determining caseload assignmentsinclude:• Intensity of involvement by the case manager.• Frequency of interventions by the case manager.• Case acuity.• Skill training, roles, competencies, andexperience of case managers.• Breadth of the case manager’s responsibility.• The 2007 Dignified Treatment of WoundedWarriors Act (H.R. 1538), which determinescaseload assignments for the Medical Care CaseManager (MCCM).o No more than 17 wounded warriors inan outpatient setting are assigned to theMCCM.
Medical Management GuideVersion 3.0Case ManagementPage 81Assigning caseloads is a labor-intensive processthat includes creating and implementing the planof care, as well as maintaining documentation ofprogress toward target goals. Managing the balanceof tasks is a critical factor in helping case managersexperience job satisfaction in their day-to-dayresponsibilities. More specifically, assigning a genericratio of patients to a case manager (a “one ratiofits all” approach) does not support case managers’ability to consistently reach optimal outcomes fortheir patients. When determining what constitutesa manageable caseload, applying the CMSA’sresearch and lessons learned from implementinga CM program can generate an environment thatsupports the most desirable patient outcomes.Discharge PlanningDischarge planning helps sustain or enhancethe gains achieved from hospitalization for thecontinued health and welfare of patients andtheir families following discharge. Mullahy (1998)describes discharge planning as “assessing thepatient’s need for treatment after hospitalizationin order to help arrange for the necessary servicesand resources to affect an appropriate and timelydischarge.” Discharge planning can be providedin multiple settings, whether transitioning thepatient from an inpatient hospitalization to anotherinpatient facility or residential treatment facility; orfrom an inpatient to skilled nursing facility, homehealth care, or high-intensity outpatient services.Discharge planning is critical, as shorter hospitalLOS are typical. Ideally, discharge planning begins atpreadmission. In planning the appropriate discharge,the case manager must spend time speaking withpatients/caregiver(s) to determine what they needand are willing to do at the next level of care, andwhich resources are available at home. Supportcan range from video teleconferencing with aDepartment of Veterans Affairs (VA) polytraumacenter to holding conference calls with the family orfacilitating site visits.The staff nurse may perform discharge planningactivities when caring for the patient on theinpatient unit. However, the case manager isresponsible for overseeing discharge planningactivities and for executing the plan as designed.The discharge planning process includes thefollowing steps.1. Assessment. The discharge planner isresponsible for assessing every patient onadmission for discharge planning needs — ata minimum every 72 hours until discharge, perMcKesson InterQual guidelines (see SectionII, Utilization Management). The dischargeplan must align with the TRICARE benefit andpolicies. Therefore, it is also important forthe discharge planner to obtain informationregarding the patient’s enrollment status, as thisaffects the authorization of plan of care upondischarge.2. Referral. Consideration must be made if referralsneed to be sent to a social work case managerto address patient/family social issues or to makearrangements such as nursing home placement.Referral can also mean obtaining TRICAREreferrals and authorizations to execute thedischarge treatment plan. For example, a patientmay require assistance with home IV infusiontherapy. In this case, referrals and authorizations
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