Care Coordination

Case Management
Disease Management

Nermin Mahmoud Ghith

B.S., PGDip.TQM, C.P.H.Q
Healthcare Quality Consultant
Nermin_ghith@hotmail.com
Care Coordination
 Definitions
Care coordination involves
management of the delivery of
services to both the individual
patient/client (case management) and
selected populations.
Continuity of Care means the
coordination of needed healthcare
services for a patient or specified
population among all practitioners and
across all involved provider
organizations over time
 Case Management
Case management is an area of practice
within several healthcare professions.
Most case managers are nurses or social
workers.

The Case Management Society of

America defines case management as:
"a collaborative process of
assessment, planning, facilitation and
advocacy for options and services to
meet an individual's health needs
through communication and available
resources to promote quality cost-
effective outcomes."
 Case Management

Case Management refers to the clinical

and administrative coordination and
integration of all phases of a patient's
or client's care, including the
identification and orchestration of all
necessary healthcare resources, in
acute, outpatient, and community-
based settings
 Case Management

It is a process encouraging
interdisciplinary, proactive, or point-of-
service intervention by clinical
practitioners; case management/UM,
social services, and quality
management staff; and leaders to
promote and provide quality, cost-
effective patient care through an entire
episode of illness;
 Case Management
Essential Components
Assessment and planning
Coordination and referral
Coordination of treatment
Monitoring of processes

N.B.:
CM Not a new concept
Utilized by Social Service and Psychiatry for
years
 The General Purposes of Case
Management
Organizing and coordinating services and resources
to meet an individual's healthcare needs;
Ensuring appropriate use of the healthcare system;
Providing and managing episodes of care for patients
Providing quality care along a continuum;
Decreasing fragmentation of care across many
settings;
Enhancing clients' quality of life
Containing costs.
 Case Management Models

Reimbursement based-- control cost

and coordinate services
Institution based---usually found in
hospitals, home care agencies, or
nursing homes
Social Service based---found in the
social welfare arena
Private management based--employed
by patients or their families to provide
life planning of finances and
healthcare.
 Essential Features of a Case
Management Program
Established methods of screening/
targeting/ identifying appropriate patients/
clients, e.g.
Predetermined diagnoses
Multiple hospital admissions or ED visits
Comprehensive individual assessment
and diagnosis procedures;
Care plan development, including service
planning, resource identification, and
linkage of patients/clients to needed
services;
 Essential Features of a Case
Management Program
Care plan/service implementation and
coordination; Monitoring of service
delivery;
Thorough documentation and reporting
of activities;
A method of reassessing patient/client
status and evaluating service outcomes;
Patient advocacy approach.
 Disease Management

Disease Management" refers to the

management of chronic disorders across the
continuum of care
Diseases are selected on the basis of:
Chronicity
High costs of care over time
High patient volume
Treatment by both primary care and specialist
physicians
Wide variance in practice patterns
Significant potential for patient involvement
 Disease Management may include:

Use of practice guidelines and clinical

pathways
Use of appropriate specialist as primary care
practitioner PCP for some chronic diseases
Patient/family education/ Provider education
Outpatient drug management
Physician buy-in and support
Triage protocols
Risk assessment tools aimed at primary,
secondary, and tertiary prevention
Group visits in place of individual visits
 Discharge Planning

Component of Utilization Management

Begins upon admission
Moves the patient through the system
effectively
efficiently
Requires an organizational focus
 Discharge Planning
Daily care conferences involving all
disciplines on all inpatient locations
Weekly utilization management meetings
Attendees:
Quality Management
Social Service
Administration (1)
Finance
Inpatient Unit Directors
Home Care
Purpose: Discuss all patients with LOS >5
days
Group decision making about moving patients
through the continuum
 Implementing Discharge
Planning Programs
Critical to utilization program
Methods of patient identification
pre-certification
diagnoses
Additional roles
Legal considerations
 Implementing Discharge
Planning Programs
Continuum of Care: more comprehensive
approach

1. Critical to utilization program: promotes

efficient use of resources; ensures appropriate
disposition; decreases risk/liability due to
premature discharge; multidisciplinary team
coordinated by one member
2. Patient identification
1) pre-certification (actually preadmission):
useful with elective procedures; provides
most holistic approach to management of the
continuum of care
2) diagnoses: allows for prioritization of
cases;
high cost/high risk/problem prone discharge
cases
 Implementing Discharge
Planning Programs
3. Additional roles:
patient education: patient and family buy-in
for timely discharge plan
healthcare team education: knowledge of
community resources

4. Legal considerations: Organizations need

policies to address at least the following to
decrease liability exposure:
patient competency: policy addresses
process to ascertain competency: impacts
LOS/payment/quality
third party discharge planners: policy for
monitoring and supervision on on-site activity
suspected maltreatment: policies to address
sources, assessment, reporting, and follow up
 Implementing Patient Advocacy
Program
Systematic problem solving
Basic patient rights
Management of concerns, inquiries,
complaints
Processing complaints
Tracking and trending
Implementing Patient Advocacy
Program
1. Systematic problem solving:
helps organizations meet patient needs
and improve customer satisfaction.

2. Basic patient rights:

Cornerstone of customer satisfaction;
policy development with consideration to
regulations/applicable standards; patient
education of rights/policy via posting,
pamphlets
Implementing Patient Advocacy
Program
3. Management of concerns:
covers all aspects of patient experience
(clinical, physical environment/structure)
staff position/role
staff member education
develop policy/procedure
Patient education via
posting/pamphlets
4. Processing:
policy and procedure define
responsibilities, chain of command, time
frames, responsibility to patient/family
5. Track/trend:
key role for HQP and the PI program
 Managed Care
An integral part of patient care processes in
every healthcare organization:
The balance of cost, quality & risk issues
& systems in a competitive healthcare
environment
An integrated clinical/financial approach
to patient care management & service
delivery
A transfer of information, of consensus,
across, in, & through services and
settings
Vertical & horizontal integration of patient
care
 Demand Management
The term demand stems from the
concept of supply & demand
In the past healthcare marketing
focused on the supply side (provider):
Do you want what I have to offer?
Now, the demand side
(patient/member) now asks: Do you
have help & resources to meet my
need?
 Demand Management (cont.)
In managed care, demand
management involves the use of
decision and behavior support
systems to appropriately influence
individual patients/members
decisions about whether, when,
where, & how to access medical
services.
Demand management incorporates
tele-service technologies, triage,
algorithm-driven care guidelines &
provider database.
 Demand Management
Support Systems
Telephone 24 hour call centers or
hotlines
Easy-to-access health & resource
information
Self-care books & other
communications
Group & individual education programs
Lifestyle & stress management
Patient/member counseling
Sophisticated information systems
Physician approval of protocols,
algorithm.
 Demand Management
Services
Manage utilization
Improve access to needed care (Timelines &
appropriate level)
Link consumers of care to all appropriate
information & care options
Track/monitor patients conditions
Enhance patient/member health education &
participation in care
Provide data to better address the needs of
members & patients and to make strategic
decisions about benefits.
Link demand, enrollment, claims, clinical &
provider profiling database
Thank You