Life Sciences

Messaging to case managers should address integrated models

Medicare & Reimbursement Advisor Weekly, April 29, 2009

Editor’s note: Case managers in the acute care setting are becoming more involved with health plan case managers and are an important influencer for messaging. The following story is about a developing trend in case management involving medications.

As a utilization review nurse in the psych unit of Fulton County Health Center in Wauseon, OH, Tina Leach, RN, CCM, regularly sees that a lack of integrated care management can cause problems on a hospital floor. Although Leach admits the need she sees for integrated case management is amplified in the psych unit, the former emergency department nurse says the need is pervasive and affects each unit of the hospital. The pressure is on for case managers to reduce readmissions and prolonged length of stay (LOS), which may be caused by a lack of integrated care management.

“Ohio Medicaid is looking a lot now at readmissions. Fifteen years ago, that wasn’t the hospital’s problem, but now we’re looking at denials … I expect issues with Medicare reimbursement will come around too,” Leach says.

For the past two years, Becky Perez, RN, CCM, CPUR, CPUM, an independent hospital case manager, and Roger Kathol, MD, adjunct professor of internal medicine and psychiatry at the University of Minnesota, have studied the benefits of an integrated case management program. According to their study, 5% of patients are complex and use half or more of a facility’s healthcare resources. More than two-thirds of this small group has concurrent physical and mental health/substance use disorders, yet a lack of communication about clinical assessments and treatment can result in an upsurge of issues. “Interaction is limited … this disintegrated care leads to poor clinical outcomes, high total healthcare costs, and reduced productivity,” says Kathol.

According to the study, an integrated case management solution can save a typical hospital an average of 115 days and $2.9 million over a two-year period. “When a patient falls through the cracks, you look at prolonged length of stay, inappropriate discharge planning, and readmissions,” says Kathol.

Perez and Kathol created a relationship-based evaluation tool that assesses the complexity of each patient. (For a copy of the tool, contact Editor Bryan Cote.) “By identifying four domains, we hope to identify barriers to improvement. How a patient is scored will lead to action by the case manager, medication decisions, and a care plan will develop from documentation in this grid,” says Kathol.

Integrated training allows case managers to proactively help hospitalized patients by increasing their ability to:

Flag and interview high-risk patients for complexity during admission evaluations

Link multi-domain (e.g., biological, psychological, social, insurance, and health system) barriers to improvement with specific management activities

Reduce the occurrence of adverse hospital events and shorten LOS

Prepare complicated patients for discharge

Improve access to complexity-based post-discharge community services


Managed markets need to figure out how their products and programs can help hospitals reduce readmissions and meet their growing need for integrated case management, says Leach. “With mentally ill and, especially, chronic mentally ill patients, you need to start their plan of care with an understanding of their issues,” she says. “Follow-up is important: Do they have issues with staying on their meds? Do they have issues at home? When you let one issue fall through the cracks, you see it multiply as a problem.”

Integrated health management requires a willingness to look at the whole patient—not just the physical illness, says Perez. Hospital case managers can obtain a baseline for the integrated care management plan and, by assessing the patient’s additional needs, make referrals to the appropriate providers, refine the patient’s medication plan, and inform existing providers of what is needed to better manage the patient’s illnesses and behaviors.