Quality Assurance Program Case Management Order Instructions: Case Management module 3

Assignment Expectations

Please view this short video before starting this assignment:

What is Case Management?

Case management programs are usually considered to be an element of the Quality Assurance Program. However, some health care professionals believe that they may be more interested in managing costs rather than the quality of care. Considering this issue please respond to the following questions in a 4- to 6-page paper:
1. Do you believe that case management programs are more concerned with reducing costs or improving the quality of care? Please justify your position.
2. Generally, discuss the limitations of a typical case management program and their strengths.
3. Do you believe that case management programs will become a medical program necessity in the future? Justify your position.
4. In your opinion, how important are “gatekeepers” to the case management process?

Quality Assurance Program Case Management References

Collins, D., Jarrah, Z., Gilmartin, C., & Saya, U. (2014). The costs of integrated community case management (iCCM) programs: A multi-country analysis. Journal of Global Health.

Curtis, J. L., Millman, E. J., Struening, E. L., & D’Ercole, A. (2014). Does outreach case management improve patients’ quality of life?. Psychiatric services.

Hendricks, V., Schmidt, S., Vogt, A., Gysan, D., Latz, V., Schwang, I., Riedel, R. (2014). Case Management Program for Patients With Chronic Heart Failure: Effectiveness in Terms of Mortality, Hospital Admissions, and Costs. Deutsches Ärzteblatt International, 111(15), 264–270. http://doi.org.ezproxy.trident.edu:2048/10.3238/arztebl.2014.0264

More, K., Moreo, N., Urbano, F. L., Weeks, M., & Greene, L. (2014). Are We Prepared for Affordable Care Act Provisions of Care Coordination? Case Managers’ Self-Assessments and Views on Physicians’ Roles. Professional Case Management. 19(1), 18-26.

Mullahy, C. M. (2014). The Case Manager’s Handbook, (5thed). Burlington, MA: Jones & Bartlett Learning. Retrieved from: http://books.google.com/books?hl=en&lr=&id=iUPyAAAAQBAJ&oi=fnd&pg=PA12&dq=concurrent+utilization+review+programs+in+nursing+homes&ots=iorEmkFyuh&sig=4YnmC-9Hh6jCoi0rK2dH58NhoIM#v=onepage&q&f=false

Phillips, R. L., Han, M., Petterson, S. M., Makaroff, L. A., & Liaw, W. R. (2014). Cost, Utilization, and Quality of Care: An Evaluation of Illinois’ Medicaid Primary Care Case Management Program. Annals of Family Medicine, 12(5), 408–417. http://doi.org.ezproxy.trident.edu:2048/10.1370/afm.1690

Talisman, N., Kaltman, S., Davis, K., Sidel, S., Akil, M., & Alter, C. (2015). Case Management: A New Approach. Psychiatric Annals, 45(3), 134.

Young, M., Sharkey, A., Aboubaker, S., Kasungami, D., Swedberg, E., & Ross, K. (2014). The way forward for integrated community case management programmes: A summary of lessons learned to date and future priorities. Journal of Global Health, 4(2), 020303. http://doi.org.ezproxy.trident.edu:2048/10.7189/jogh.04.020303

Quality Assurance Program Case Management Websites

The question of the Week: TJC Requirements for Utilization Review Plan at http://blog.mcnhealthcare.com/2011/01/20/gq411/

Module Overview

Introduction

Case management, which is sometimes referred to as care management, is frequently used for patients that have complex problems and require numerous services over an extended period of time. Case management programs are sometimes called Rare and Expensive Case Management programs by some healthcare organizations.

Regardless of the type of case management program, they all have a similar purpose to coordinate the care and treatment for patients with serious and life-threatening conditions over an extended period of time. An example of an illness which requires both medical and social services are Acquired Immune Deficiency Syndrome (AIDS), spinal cord injury, and paraplegics.

Case managers are usually not involved with the patient and their treating physician where primary care needs are limited. However, when a patient requires long-term care, specially trained case managers may be able to more efficiently coordinate and monitor the delivery of health care services. In this role, the case manager can have a positive impact on the quality of services provided to the patient.

Case managers always consult with primary and secondary care providers to determine what care is required and they arrange for patients to receive the agreed-upon care in the most appropriate and cost-effective setting.

Actually, case managers are often thought of as gatekeepers because of their role in controlling utilization of health care services. In the role of a gatekeeper, the case manager coordinates hospital admissions, surgical consultation, specialist consultation, diagnostic testing, and social services. They also make secondary care referrals and are usually involves a primary care delivery consultations.

Case management has evolved over the years as a specialty position in many health care organizations. For instance, case managers can specialize in home health care, rehabilitation, long-term care, mental health, hospitalization inpatient surgery, outpatient surgery, and even surgical evaluation.

Other areas of case management where specialized skills are required are in the area of Disease State Management, transplant facilities, and high-risk pregnancies.

Case management has become an important element for providing quality care and certainly should be part of every quality assurance program.

Quality Assurance Program Case Management Sample Answer

1. Do you believe that case management programs are more concerned with reducing costs or improving the quality of care? Please justify your position. 

Case management programs are designed so as to improve healthcare quality and to reduce the cost of care. Case management is a key element in Quality Assurance program and often used in patients diagnosed with chronic and complex health complications that need numerous healthcare services for a long period of time (Curtis, Millman, Struening, & D’Ercole, 2014).

Case management ensures that the cost of care and quality of care that were previously on the opposite side of the health care delivery spectrum are integrated into one system. Case management is used as a cost containment strategy, and further grounds the managed care by focusing on individual care needs to a patient. It has been argued that a case management program is more concerned with managing costs of care than quality. There is mixed evidence on this matter, but case management programs to improve service utilization by reducing the length of stay, admissions, and cost of care. In this context, it is correct to argue that the case management program is effective in ensuring the quality of care as it coordinates professionals, integrates evidence-based practice during care delivery and evaluates the outcome of the care process. Consequently, there is renewed interest in utility and effectiveness of such care systems (Collins, Jarrah, Gilmartin, & Saya, 2014).

Case management ensures the delivery of quality care by demanding accountability from healthcare team members assigned to patients. The program also provides clear directives about the role of each team member in order to ensure that the patients receive right and appropriate managerial competencies. The accurate findings of case management programs ensure that gaps and challenges are addressed using effective interventions and that patients being cared managed  receive optimum care, thereby improving both the quality and cost of care (Hendricks et al., 2014)

2. Generally, discuss the limitations of a typical case management program and their strengths.

In the current healthcare industry, the healthcare providers are under pressure to deliver quality care and to reduce the cost of care by eliminating unnecessary costs. This requires improved coordination between the healthcare providers, which is successfully achieved by using case management programs. However, there are some limitations that face case management across healthcare continuum (Philips et al., 2014).

The strengths of the case management program are that it ensures that each patient receives evidence-based care as the patients have designated case manager who has expertise regarding the specific patient’s care needs and delivery system. With their broad knowledge base of care services available, case managers learn on exact approaches to assist patients in accessing the care services. However, this pro can be a con, especially if the case managers have inadequate knowledge regarding specialized services beyond the area if their expertise (Collins, Jarrah, Gilmartin, & Saya, 2014).

In addition, there is no standards protocol or universal case manager training on core competencies necessary for case managers. In some cases, case management managers face complex and increased legal issues. They have to ensure that patient privacy and confidentiality is maintained during coordination of care between the various team members and ensure that they comply with healthcare reform legislation and HIPAA guidelines. This makes it challenging to produce optimal care while navigating the legal and ethical boundaries (Young et al., 2014).

Another limitation is the fragmented healthcare system that creates a barrier to effective case management systems by limiting the ability of healthcare facilities to manage for cases they cannot control. For instance, organizational independence of alternative care delivery facilities such as nursing homes and home care agencies have limited ability to continue managing for their patients once they are discharged (Mullahy, 2014).

3. Do you believe that case management programs will become a medical program necessity in the future? Justify your position.

The future of healthcare system requires the healthcare provider to seek for unique solutions to the dynamic and challenging healthcare environments that impede the ability to deliver quality care while maintaining a cost of operations within a manageable level.  Therefore, the case management program is very important and will still be very vital in the future (Talisman et al., 2015).

With the increased reforms in the Affordable Care Act, it is predictable that the future paradigm will be focused on keeping patients out of the hospital as much as possible. This implies that once a patient is in the hospital, the healthcare providers will be required will need to make establish the most effective care plan as much as possible, a plan that will monitor patient’s progress and outpatient follow-up until recovery. Although this is not a difficult task, case management programs are new concepts to most healthcare systems. It is evident that case management will gradually become a process that will be integrated to all continuum care programs, in order to develop a mechanism of monitoring patients continually using disease-specific and individualized care plans (Moreo et al., 2014).

Technology will have a major role in this process. This is because it will make it easy for outpatient monitoring for patient being case managed by making it easier to send the information to case managers and to give alerts in case of unexpected results. Technological advancements will ensure comprehensive care management plan because it will be cost effective and easy for doctors to go to patient’s homes that to rely on ambulatory services to bring non-critically sick patients to the ER (Hendricks et al., 2014).

4. In your opinion, how important are “gatekeepers” to the case management process?

A gatekeeper is a primary care provider who is assigned to a patient being case managed. The gatekeeper is responsible for managing referrals for special care and other covered services needed by the patient. The role of gatekeeper is important in case of management program because they screen all patients for appropriateness of admission in order to control service utilization and cost of care. They also determine the level of care needed by the patient. For instance,  the gatekeeper protects inappropriate admissions by reviewing potential admissions before they are processed. This helps in reducing the cost of care and effective service utilization- which are the core components of the case management program. Once a physician completes their medical screening exam and they want to admit their patients, the gatekeeper analyses the process and compares the reason for admission against the utilization review criteria so as to determine if admission is necessary. This not only improves resource utilization but also improves the quality of care by ensuring that the patient gets adequate care without issuing unnecessary medical services(Young et al., 2014)..

Lastly, gatekeeper position is important because it helps managing and monitoring of variances, including all elements that may lead to resource misuse or lengthened stay for instance in emergency departments for what would have been an outpatient service. They do so by critically analyzing patient’s condition to identify the available resources and to seek alternative sources where appropriated so as to ensure the quality of care is sustained.  This way, the gatekeeper ensures smooth coordination of care by keeping the involved healthcare providers with the relevant information and through documentation processes (Mullahy, C. M. (2014).

Quality Assurance Program Case Management Reference

Collins, D., Jarrah, Z., Gilmartin, C., & Saya, U. (2014). The costs of integrated community case management (iCCM) programs: A multi-country analysis. Journal of Global Health.

Curtis, J. L., Millman, E. J., Struening, E. L., & D’Ercole, A. (2014). Does outreach case management improve patients’ quality of life?. Psychiatric services.

Hendricks, V., Schmidt, S., Vogt, A., Gysan, D., Latz, V., Schwang, I., Riedel, R. (2014). Case Management Program for Patients With Chronic Heart Failure: Effectiveness in Terms of Mortality, Hospital Admissions, and Costs. Deutsches Ärzteblatt International, 111(15), 264-270. http://doi.org.ezproxy.trident.edu:2048/10.3238/arztebl.2014.0264

Moreo, K., Moreo, N., Urbano, F. L., Weeks, M., & Greene, L. (2014). Are We Prepared for Affordable Care Act Provisions of Care Coordination? Case Managers’ Self-Assessments and Views on Physicians’ Roles. Professional Case Management. 19(1), 18-26.

Mullahy, C. M. (2014). The Case Manager’s Handbook, (5thed). Burlington, MA: Jones & Bartlett Learning. Retrieved from: http://books.google.com/books?hl=en&lr=&id=iUPyAAAAQBAJ&oi=fnd&pg=PA12&dq=concurrent+utilization+review+programs+in+nursing+homes&ots=iorEmkFyuh&sig=4YnmC-9Hh6jCoi0rK2dH58NhoIM#v=onepage&q&f=false

Phillips, R. L., Han, M., Petterson, S. M., Makaroff, L. A., & Liaw, W. R. (2014). Cost, Utilization, and Quality of Care: An Evaluation of Illinois’s Medicaid Primary Care Case Management Program. Annals of Family Medicine, 12(5), 408–417. http://doi.org.ezproxy.trident.edu:2048/10.1370/afm.1690

Talisman, N., Kaltman, S., Davis, K., Sidel, S., Akil, M., & Alter, C. (2015). Case Management: A New Approach. Psychiatric Annals, 45(3), 134.

Young, M., Sharkey, A., Aboubaker, S., Kasungami, D., Swedberg, E., & Ross, K. (2014). The way forward for integrated community case management programmes: A summary of lessons learned to date and future priorities. Journal of Global Health, 4(2), 020303. http://doi.org.ezproxy.trident.edu:2048/10.7189/jogh.04.020303