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Mentor moment: Case management protocol is still debatable

Case Management Weekly, February 23, 2011

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CMS’ reiterated in the special edition MLN Matters article SE1037 that inpatient screening tools such as InterQual^® and Milliman^®, may assist facilities in making patient status determinations, but the physician must make the ultimate call.

This presents a problem because according to many case managers, physicians do not know the inpatient care guidelines.

“Admission status does not affect physicians’ plan of care. They will treat the patient the same whether inpatient or outpatient observation. They want the case managers to make the decision for them since they are not familiar with the guidelines,” says Kathryn Bennett, RN BS CCM, director of case management at Indiana University Health Center in Bloomington.

Some case management departments have gone so far as to implement a case management protocol in which physicians perform an initial assessment of a patient and document their medical opinions. Physicians then write an order for the case manager to make the patient status decision using screening criteria. The physician then signs off on that decision.

Many departments have been hesitant to implement case management protocol because CMS will not endorse or condemn its use. Although SE1037 reiterates that patient status is a physician decision, it does not address case management protocol.

Case management departments interested in implementing a case management protocol should consult their quality improvement organizations (QIO).

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