Case management

From HMCwiki

Case management can mean many things to many people. It can be focused on utilization management, co-ordination of Social Services, or disease specific interventions (High-risk case management). Other programs focus on those patients that use the Healthcare system the most, plan of care design, teaching those patients to take better care of themselves, and making them aware of post-hospitalization services (Disease Management).

High risk management model: finding the opportunity

The 80-20 rule very well may apply to the management of patients that become all too familiar with the location of the physician office, lab, special procedures, inpatient units, not to mention the cafeteria and gift shop. That is, it could be that 20% of the patient population is responsible for utilization of 80% of the hospitals resources. The definition of high-risk, then, means both risk to the patient and risk to the institution. Patients with multiple diagnosis and complications can also be frequent users of the Emergency Department and other outpatient services. In addition, these patients could be experiencing social circumstances that are contributing to their well-being, or lack thereof. And managing the continuum of care for these patients means not only crossing the boundary between inpatient and outpatient services, but also managing care outside the walls of the hospital. Defining the case management model of care can begin with identifying the population that fits into the "20%". While the outcome may be to drive down hospital costs, it's the right thing to do from the patient's perspective as well.

Consider this example of a "high-risk" case management model in action:

Based on a hunch that their employee utilization of their own health plan was high, OSF Saint Francis, Peoria, IL brought in an outside firm to look at their utilization patterns. They found that 1% of their employees were using 20% of the total health care dollars in their plan. They also discovered that these employees had additional problems besides their health status, including financial problems, family conflict, and emotional issues. SFMC established an employee case management team, consisting of a hospitality, a RN case manager, a social worker, and a financial counselor. They work with the relatively small number of employees (40-50) to get their health status stronger, and the other components of their lives on a more stable platform.

Disease management model: finding the opportunity

While a high-risk case management model may focus on persons with a high risk of becoming seriously ill due to a combination of medical, social and functional problems, a Disease Management Case Management model addresses standard, evidence-based needs related to a specific diagnosis. This approach depends on a large degree in developing close relationships with physicians, since the Case Manager, in this instance, will be addressing the variation in practice patterns within a diagnostic group, closely analyzing patient outcomes, then designing a common approach, or pathway, that will increase the overall outcomes of patient with these specific diagnosis. From the hospital perspective, utilizing a common approach to care-plan development, based on well-researched evidence, can reduce costs. The challenge of course is to corral the medical community into accepting a different way to approach disease management then perhaps they have approached it for many years. Those programs that involve physicians early on have the greatest chance of success.

Consider this example of a "disease management" case management model:

At a small community hospital in Kentucky, the hospital pharmacy was recognizing an increase in respiratory medication usage, especially an increase in Xopenex, a medication for the treatment of broncospasms. After a pharmacy review of medication utilization, it was discovered that this medication was being prescribed for inpatients sometimes every six (6), four (4) and even two (2) hours, even though there was no therapeutic benefit beyond every eight (8) hours, according to the pharmacist. While there was obvious savings in medication utilization, the Respiratory Therapy department was performing 28% more nebulizer treatments than if a fully implemented protocol plan called for treatments every eight (8) hours, only. The net over utilization of the Respiratory Therapy departmental overall was 17%. Another benefit of this new protocol was that because patients only needed to be treated every eight (8) hours, treatments could be staggered so patients have a better chance of sleeping through the night, without being woken for a treatment.

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