Case Management

The RAC effect: How RACs influence case management

Case Management Monthly, November 1, 2009

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Healthcare professionals must also substantiate their clinical judgment as to why a patient needs to remain in a given level of care on a daily basis. The case manager should confirm that the documentation is accurate and consistent with the hospital’s level-of-care criteria (e.g., Milliman, Interqual). If clinical documentation is not consistent with screening criteria, it must define the rationale for treatment decisions.

Another major component of evidence-based care is developing clinical protocols that define all the components of care for specific illnesses. The case manager can be instrumental in convincing a hospital’s risk manager, quality manager, and clinical leaders of the benefits of well-written clinical protocols. The case manager should be a central member of a clinical team that reviews the literature, confirms the validity with the facility’s screening level-of-care criteria, and secures the endorsement of the medical staff. The case manager should then be accountable for ensuring that the clinical staff implements the protocol when appropriate.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Case Management Monthly.

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