CHANGING CAREERS CASE MANAGEMENT UTILIZATION REVIEW & DISCHARGE PLANNING WORKSHOP ALL RIGHTS RESERVED BY MGK. INC. COPY RIGHT 2005

SESSION I: I. Introduction to Case Management Concept, Principles, and Methodology Il Goals and Behavioral Objectives ❖ Discuss the objectives of Case Management (Job description of the Case Manager) ❖ Goals of a Case Manager ❖ Roles and responsibilities of the Case Manager ❖ Understanding federal/state rules and regulatory guidelines as they are related to Case Management and their standards of care criteria ❖ Understanding the financial role and relationship between the facility, payors, and how it relates to Case Management understating the hospital leadership role as it relates to Case Management ❖ Organization-commitment to collaborative Case Management ❖ Challenges and changes in Case Management since 195o's and 196o's ❖ Quality of care and Case Management ❖ Nursing and Social Service Case Management ❖ Unit Base vs. Disease Case Management ❖ Commercial and Managed Care Case Management ■ 01

III. A Day in the life of a Case Manager ❖ Daily responsibilities of the Case Manager ❖ The beginning of the Continuum Of Care Process ❖ Pre Admission Screening (the appropriate criteria is met (SI/IS)) ❖ Understanding admission criteria ❖ Prioritizing your case load ❖ Importance of the initial assessments/establishing a discharge plan ❖ Interdisciplinary case meetings ❖ Addressing quality of care issues ❖ Interfacing with the medical staff ❖ Prioritizing your discharges ❖ Identifying/ understanding over and under-utilization and how it affect your WS ❖ Pre-exempting a Denial /Denial letters and the patients rights ❖ The importance of tract and trending delay of service ■ 02

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VI. VII. VIII. ♦:♦ ♦:♦ ♦:♦ ♦:♦ •:• •!• ♦:♦ ♦:♦ ♦:♦ ♦:♦ •:• •!• •!• ♦:♦ •!• •!• Continuum Of Care Standards Department Standards Documentation Joint Commission Standards Critical Components Confidentiality (HIPP A) Case Management Liability Payer Reimbursement (Per Diem, Contract & DRG) EBM ( Evidence Base Medicine Criteria) Utilization Review and Denial Management Utilizing criteria/ identify criteria used in the utilization process Discuss review process and it implications Legal responsibilities of the Case Manager Identify data collection types, quality indicators related to denials, tracing denials Appeals/Grievance process, reasons to avert lost reimbursement related to the review process Guidelines, denials prevention, correct documentation with timely payer telephone calls to avoid denials Understanding Evidence Based Criteria What is evidence based criteria and who uses it Understanding the criteria for InterQual and MCG criteria based upon federal guidelines associated with the review process for admissions, primary, and secondary reviews. Intensity of Service, Severity of Illness and Discharge Screening ❖ How to make the criteria work for you I 04

❖ Medical Staff, the Case Manager and the patients. Making criteria based documentation work for you. The do' s and don't s how to reverse a denial using established criteria. IX. Making the Most of Utilization Management ❖ Enhancing a positive working relationship with the medical staff, controlling cost per case, managing clinical resource utilization and managing commodities ❖ Quality and the Continuum, of care, tracking delay of service ❖ CM/Utilization Review Indicators and Forms ❖ Practical tips to efficiently manage a Case Management assignment, track and trend for quality issues, risk management, legal issues, and development of tools and the reporting process ❖ The Case Manager's role in the medical staff re-credentialing process X. DISCHARGE PLANNING/ SOCIAL SERVICE REFERRALS ❖ Professional coordination of care and services throughout entry, assessment, diagnosis, planning, treatment and transfer or discharge of the patient. XI. Acute Care Glossary of Terms and Abbreviations ❖ Definition of frequently used medical terms, abbreviations, and acronyms • 05

Session ill .. XII. Explanation of Payer Sources A. Medicare/CMS ❖ Establish a foundation of knowledge specific to benefits who qualifies, old and new changes to patients and facilities discuss old and new ways to tackle your Medicare LOS. (Length Of Stay) Understanding the difference between Medicare A and Medicare part B- Benefits. The importance in knowing the difference between the two. ❖ Documentation issues related to part B benefits. How to issue a letter of denial using your (CMS) when the patient no longer meets acute care criteria a how it works. Patient's rights to an appeal and the process of filing request for a outside CMS Quality Review. New Medicare guidelines for physician certification 1599F Rule and Medicare SNP (Special Needs program) B. Medicaid ❖ Update your Medicaid (Medi-Cal) Knowledge, benefits and who qualifies. Old and new changes to patients. Discuss old and new ways to tackle your Medicaid denial and LOS. Documentation issues that is sometimes associated with Medicaid./Medi-Cal ❖ Medicaid (authorization request) getting the most from your documentation. ❖ How to appeal my Medicaid/Medi-Cal denial C. Commercial ❖ Update your commercial insurance knowledge, benefits and verifications, co-payment and pre-approvals. Discuss old and new ways to tackle your Commercial denials. ❖ Documentation issues that is sometimes associated with commercial payer denials D. •!• Hospitalists, Intensivists, what they mean to me and the commercial I 06

I. INTRODUCTION TO CASE MANAGEMENT (CONCEPT, PRINCIPLES, & METHODOLOGY) I 07

"W HAT IS CASE MA NAGEMENT ?" WHO CAN PERFORM IT? Case Management is a philosophy of healthcare tied to population that is providing its value to patients, communities, physicians and chief financial officers Multidisciplinaiy approach is used for quality improvement, and preventive healthcare paradigms. Case Management is effective to ensure the appropriate length of stay (WS), efficient utilization of resources, and best patient's outcome. "The Case Management fundamental focus" is to integrate, coordinate, and advocate for individuals, families and groups with optimal focus on good healthcare." The ultimate goal is to achieve the planned of care outcome by procuring and negotiating services across the healthcare continuum, and to insure the best patient outcome. The Joint Commission: Defines Case Management as "a process used to manage and coordinate health care resources for care and services." Organizations use case management to meet several goals. Six steps: .Assessment, Planning, Implementation, Coordination, Monitoring, and Evaluation. ❖ Coordinate patient or groups of patients across an episode or continuum process. ❖ Ensure achievement of quality, and clinical cost outcome. ❖ Negotiate, procure, and coordinate services, and resources needed by patients and their families. ❖ Intervene at key points What Joint Commission standards apply to Case Management (CoP) Conditions of Participation for Case Management, specifies that the hospital must ensure coordination among health professionals, services, and settings for a patient's care. Professionals coordinate care throughout entry, assessment, diagnosis, planning, treatment, and transfer or discharge. They match patient's needs with appropriate resources throughout the continuum (such as special-care units, skilled nursing facilities, or community services). Coordination of services may involve promoting communication to facilitate family support, social work, nursing care, clinical consultations or specialty referral, primary physician care, or other follow-up on significant variances in care for individual patients. 08 I

❖ Resolve patterns in aggregate variances that have a negative quality cost-impact ❖ Create systems to enhance outcomes Case Management Standards: Interdisciplinary Approach: Using an interdisciplinary approach the case managers facilitate admission, referral, transfer, and discharge of patients to varying levels of care, health professionals, or settings, based on the patients' needs and the organization's capacity to provide care. They also educate patients and families about healthcare needs and resources. Does a Case Manager need to be an RN? Per Joint Commission standards the organization leadership defines qualifications and performance expectations for all staff positions. In various healthcare setting RN's, LVN's, Social Workers, or Physicians may assume Case Management roles. ■ 09

NOTES NOTES Q U EST IONS NOTES NOTES NOTES NOTES NOTES NOTES • 10

Nursing Case Management ► Now that we have answered that question, let's talk. Although Case Management is by no means limited to the field of, nursing over the past 48 years has moved to the forefront as the primary professional and discipline that assumes this role and now growing number of physicians are rapidly joining the profession. A growing need for Case Management and why ► The time required searching for the appropriate level of care and resources or frequently the scurrying it takes to locate the payer source. ► The multiple gaps and fragmentation found primarily in acute and post-acute arena, which often leads to dehumanized care as patients are shifted, dropped or denied access programs. ► A myriad of chronic conditions many serious complications and any of which can be costly, required frequent treatment or encounters with healthcare systems. In the Beginning there was Social Services, Discharge Planning, Case Management, Medicare, Commercial, Managed Care and HMO ► How did Case Management Began? Ti.meF:ra.me ► Social work and case management were both born out of the Settlement House Movement in the early 20th century, when social workers helped the poor and those with health problems, connecting them with important resources and advocating on their behalf. Fea.�:res ► Case management further developed in the 1950s and 1960s with the process of deinstitutionalization, when mental institutions were closed. This led to more people in need of community-based services and, in turn, an increased need for coordination of these services. CI1si.d.e:ra.ti.I1S ► In the latter part of the 20th century, medical case management developed into a profession in its own right. Since the early 1990s, with the implementation of managed care, hospitals have had to cut costs and shorten patient's length of stay. Therefore, medical case managers have become in increased demand, specifically in the role of discharge planning. 11

► Read more: http://www.ehow.com/facts 6826678 hist0r,·-medical-case-mana2ement.html ► Title XVIII of the Social Security Act of 1965 created Medicare and with it came the mandate for discharge planning. ► Discharge planning is the strong forerunner of today's Case Management. Common Threads in Healthcare. ► The Case management role and responsibilities vary according to the organization it represents, the population served, the level of physician involvement, the culture of the organization, the client mix, the Case Managers education and training, the type of Case Management offered. , HIGH RISK CASE MANAGEMENT There are more modalities for treating high risk patient populations in today's health care arena. ► Disease case Management ► Demand Case Management ► Telemedicine ► Home Visits Case Management ► Filed Case Management Case Management is no longer limited to acute hospital settings or private insurance payers; the scope hof Case Management is very broad and mandated by the federal govermanet ■ 12

Variety of entities in the field of Case Management Post Acute Arena: ► Home with Home Health Care ► Disease specific and other community-based providers and organizations ► Skilled Nursing Care (SNF) ► Long Term Care (LTC) ► Durable Medical Equipment for home use ► Outpatient Case Management ► Acute Rehabilitation Care Center ► Free Standing Infusion Centers ► Outpatient Mental Health Centers Federal Integration: ► Case Management is now mandated to be integrated into state and federal policies associated with delivery of health care and social support systems as well as Medicaid, Medi-Cal, Medicare, Workers Compensation and many federally funded demonstrated programs. 'll 13

II. GOALS & BEHAVIORAL OBJECTIVES ■ 14

Case Management for the RN /L VN /Discharge Planner Course Outline Program Goals; The candidate will learn the process, concept, principles, and methodology, of Case Management, Utilization Review, Utilization Management, Discharge Planning and JCAHO Standards as they relate to the Continuum of Care. This knowledge will enable the candidate to effectively identify the criteria for the patient's Severity of Illness and Intensity of Service, while performing effective chart reviews to insure that the patient is transitioning appropriately through the continuum of care. The candidate will have the ability to correlate the patient's clinical picture with quality of care indicators and identify preexisting conditions to prevent over & under utilization, while assuring that the plan of discharge has been initiated and is being followed through. The prospective Case Manager will be able to successfully complete a Medi-Cal Treatment Authorization Request (18-1), as well as understanding the federal government's health insurance standards and guidelines for Medicare patients', utilization of benefits and DRG payments. The candidate will have working knowledge of all payer sources, as well as the grievance and appeal process and guidelines related to appeals. Behavioral Obiectives: At the conclusion of this course the nurse will be able to function in the Case Manager role, which will be demonstrated through their ability to initiate and perform a detailed multidisciplinary approach to the patient, assuring the patient's best outcome as they move throughout the continuum of care process. The candidate will be able to identify efficient utilization of resources, perform effective reviews, while working in conjunction with the medical staff to assure that the plan of care has been met and the discharge plan is appropriate. ■ 1s

III. A DAYINTHELIFEOF A CASE MANAGEMENT I 16

roDffl WHAT DO CASE MANAGERS DO? Case Managers are the "hub" of various information streams and collaborate with many disciplines to streamline patient care processes. They are instrumental during planning, implementation, and evaluation phase of patient care. CASE MANAGEMENT DUTIES: ► Pre-authorization of admissions ► Pre-certification for expected procedures ► Payer Verification (check with admitting for verification) ► Bed placement (appropriate level of care) ► Screen for Severity oflllness and intensity of service (SI/IS) ► Coordinate patient or group patient or group patient care across an episode or continuum (plan of care should be established within the first 24hrs of admission). ► Managing your Medi-Cal, Medicaid, Medicare, and Commercial patients Case Management and Utilization Review process ► Concurrent case reviews ( what you should look for) ► Discharge planning-within 24hrs of admission ► Negotiating, procuring, and ooordinating services, and resources needed by patients and their families ► Booking for post acute continuum of care (SNF, ARU, and ECT.) ► Patient family education before discharge ► positive working relationship with physicians and specialists; primary care, practitioners, hospitalists, intensivists, while oontrolling cost per patient day • 17

Continue Today's Goals ► case/clinical resources utilization and managing comorbidities ► Ensue achievement of quality and clinical cost outcomes ► Intervene at key points or significant variances for individual patients ► Resolve patterns in aggregated variances that have a negative quality-cost impact ► Create systems to enhance outcome ► Trackin g your LOS vs. the CMS (Medicare) LOS ► Issue denial letter when appropriate ► Monitor your denials, use criteria to verify necessity of care ► Managing your appeals/grievances (know the time lines associated with specific denials timelines). ■ 18

IVIEI>ICAL CENTER CONTINUUM OF CARE / ADMISSION ASSESSMENT - CASE MANAGEMENT DMD OFFICE DER Room#:_ __(ICU, STP, TELE, MED/SURG) ELOS: _____ _ Name: _______ �=� __ DATE OF ADMISSlON: _/ __ / __ Physician: __________________________ �------ Diagnosis: _____________________________ _ (Severity of illness) Treatment Plan: ---- (Intensity of service) Comorbidities/Pregnancy: ReAdmission: ---------------Insurance: Admitting Source: (circle one) Home SNF Subacute B&C Homeless SNF/B&C: Name: ----------Phone: ---- Able to Return: D Yes D No Transfer From Acute Hospital: ________ _ I Prio� Status: Mental Status: ASSESSMENT (circle) ... lndependent Dependent Lives Alone Home with Caregiver-Family Needs Assistance CAREGIVER NAME: _________ PHONE: _______ _ Alert & Oriented Cognitive Impairment Dementia Coma Unresponsive Confused Conservator or Surrogate Power of Attorney NAME: --------------PHONE: ------- Physical Limitations: Pertinent Info: Referral Made Based on Needs Identified: I Infections: Discharge Plan: Visual Hearing Gait Speech Swallowing Amputee NIA I Ventilator TF/PEG Dialysis 02 DME Decubitus Catheters NIA Socia] Services dietician Home Health Eligibility Worker NIA I Source: COMMENTS: _______________________________ _ CASE MANAGER: _____________________ DATE: __ / __ / __ _ ■ 19

ICE""YS TC> TIIE .A.I>lVIISSC>N" P�CESS 4 Insurance Verification 4Authorization ,-.Authorization from Case Management for Admission 20

NOlES NOTES 0 U EST ION S NOTES NOlES NOTES NOTES NOTES NOTES • 21

IV. TIME MANAGEMENT ■ 22

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