Evolving since the 1980’s, case management, an essential part of quality assurance programs, promotes excellence and efficiency in consumer health care, while conserving costs for health care organizations. Effective case managers answer the demands of changing health in promoting and facilitating a patient’s progression of care (Scott 2014). Historically, case management came to fruition as an answer to the shift of cost-based reimbursements to prospective payment models, assisting hospitals in keeping costs low regardless of the quality of care. However, as health care reform became effective, case management has grown into a newer role in assisting in the delivery of patient-centered quality care. Typically, case managers must be self …show more content…
Collaborative partnerships, among physicians and case managers, add value to the patient care by orchestrating care progression and coordination, supportive decision-making and cost-effective choices. The interaction of the case managers with multiple departments in a health system allows open communication, resulting in quality metrics demonstrating value in areas such as length of stay, observations, accounts receivable, and appeals or denials of patient care (Miodonski 2011). For instance, a patient presents with a myocardial infarction and a hospitalist orders an upper gastrointestinal series that is not necessary. The case manager in this particular situation seeks the necessity of the tests, preventing unnecessary testing and additional length of stay, ultimately improving the patient’s care and progression. Although hospital costs are avoided in this example, more importantly the case manager coordinated efficient movement and progression of care resulting in improved quality and accountability (Daniels & Frater 2011). There is no room for confusing managed care with case management, as managed care equals cost containment programs mandated by concrete systems. Case …show more content…
Typically, in current healthcare, case management assist in dissolving fragmented care for consumers, assisting in the progression of care. For example, in a hospital setting, patient care delivery provided by a combination of a surgeon, hospitalist, and a medical specialist allows for pathways of inefficient continuity of care. A case manager evaluates the entire treatment plan, managing complex care, and limiting the lack of continuity among providers (Daniels & Frater 2011). Collaboration with physicians’ decisions on clinical services and implementing accurate delivery of services by the facility exhibits strength of a case management program. However, limitations exist if physicians’ or administration do not allow the case management a respected position in decreasing healthcare fragmented delivery. Consistently, evaluation of medical goals, recommended clinical services, and patient treatment plans making sure they are in correlation with evidence based protocols and treatments, actually will improve healthcare quality, reducing length of stay and costs (Daniels and Frater 2011). Additionally, strengths of a typical case management program allow decrease in duplicate testing, improved discharge planning, and connections of ancillary departments. Case management programs assist in deleting
The current health care landscape has been characterized by large scale consolidation and vertical integration of payers and providers. This has led to a handful of dominate players with substantial influence, and an increasing overlap in responsibilities between payers and providers. Although payers and providers have traditionally been on opposing sides, battling each other about quality of care versus cost-effective care, they are shifting to working together to achieve better value.
The Crowded Clinic Case Study (Colorado State University - Global, n.d.) discusses the issues of practice management as they apply to access to care. Access to care may be as inconvenient as lengthy patient wait times to issues far more serious that may have a profound effect on the health and well-being of a single patient or an entire cohort.
Buchbinder, S.B., Shanks. N. (2007). Introduction to healthcare management. Sudbury, Mass: Jones and Bartlett Publishers Inc.
- If all of the options were explored, and patient is given antibiotics and is treated without any pain or suffering than the treatment identifies with the ethnical principles of autonomy, non-maleficence, and veracity. In turn, Mrs. Dawson will be happy with the outcome of the procedure.
When one examines managed health care and the hospitals that provide the care, a degree of variation is found in the treatment and care of their patients. This variation can be between hospitals or even between physicians within a health care network. For managed care companies the variation may be beneficial. This may provide them with opportunities to save money when it comes to paying for their policy holder’s care, however this large variation may also be detrimental to the insurance company. This would fall into the category of management of utilization, if hospitals and managed care organizations can control treatment utilization, they can control premium costs for both themselves and their customers (Rodwin 1996). If health care organizations can implement prevention as a way to warrant good health with their consumers, insurance companies can also illuminate unnecessary health care. These are just a few examples of how the health care industry can help benefit their patients, but that does not mean every issue involving physician over utilization or quality of care is erased because there is a management mechanism set in place.
The healthcare world has simply grown too large, too quickly and, as a result, has forgotten the reason behind which it stands: the patient. Continuity of care is in dire need of repair and without effective communication and coordination of care, the problem will not be corrected.
Three areas that define the provisions of comprehensive health care services and are commonly used for utilization monitoring and control are gatekeeping, case management, and utilization review (UR). Gatekeeping is used by HMOs where each member designates a primary care provider (PCP) that is responsible for coordinating all care services needed for the enrollee in a managed care plan. Case management involves an experienced health care professional with knowledge of available health care resources. `Case management services are designed to identify spec...
...lthcare system is slowly shifting from volume to value based care for quality purposes. By allowing physicians to receive payments on value over volume, patients receive quality of care and overall healthcare costs are lowered. The patients’ healthcare experience will be measured in terms of quality instead of how many appointments a physician has. Also, Medicare and Medicaid reimbursements are prompting hospitals, physicians and other healthcare organizations to make the value shifts. In response to the evolving healthcare cost, ways to reduce health care cost will be examined. When we lead towards a patient centered system organized around what patients need, everyone has better outcomes. The patient is involved in their healthcare choices and more driven in the health care arena. A value based approach can help significantly in achieving patient-centered care.
In today's health care environment many factors contribute to quality care. As a medical practice manager it is important to provide the best medical service for patients in addition to excellent levels of service. Appointment scheduling is a very important aspect of a smooth running medical practice. Appointment cancellation, no shows, and long waiting time by patients have a negative impact on the efficient running of the practice not only in lost revenue but the practices professional reputation as well (Kruse 2010).
Quality patient care is an ongoing endeavor that involves many different areas of healthcare. One area of healthcare that is often employed is Utilization Management. We read in John’s that UM “is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care” (John,2011). Things that are used to determine the appropriateness of care include the patient’s diagnosis, site of care, length of stay, and other clinical factors. This system consists of three main functions aimed at improving patient care and controlling healthcare costs. These functions include utilization review, case management, and discharge planning. One source states that it also includes the claim denials and appeals process (Interviewee C. Jarvis, e-mail communication, May 3, 2014). When used correctly, these UM processes can expedite the patient’s care and reimbursement. It also demonstrates to third party payers that the organization is taking measures to help control costs. This monitoring and management of patient healthcare needs ensur...
In the United States, nearly one-fifth of patients discharged from the hospital are readmitted within thirty days, and most of those readmissions are considered to be preventable (Verhaegh et al., 2014). Many opportunities to reduce health care costs and prevent readmissions could save Medicare as much as $12 billion a year (Constantino, Frey, Hall & Painter, 2013). These numbers are significant from a financial standpoint, but do not consider the negative impact on the patient’s experience, the perception of poor care quality and inadequate transitional care. Hospital readmissions may be linked to ineffective discharge planning, lack of care coordination, lack of outpatient follow-up care, client’s non-compliance with treatment regimen, inadequate
In 2015, the Centers for Medicaid and Medicare Services (CMS) released the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which implements the final rule which offers financial incentives for Medicare clinicians to deliver high-quality patient centered care.5 Essentially, taking the time to learn the patient’s goals and treatment preferences allows for the patient to walk away from the medical treatment or service feeling understood and cared for by the provider.4 Thus, resulting in a better, more comprehensive plan of care. Policy makers are hopeful that the new incentive-based payment system will accelerate improvement efforts.
The concept of Case management has was first introduced in the 1970’s by insurance companies as a way to monitor and control costly health insurance claims, commonly created by a catastrophic accident or illness (Jacob & Cherry, 2007). Today almost every major health care organization has a case management program managing and directing the use of health care services for their clients. Also, case management by payer organizations is recognized as external case management.
Although healthcare providers are able to have some input in the decision making process in healthcare, they truly are not always aware of what their patients want. Only a patient has the responsibility to decide what direction according to their health that they want to go. It is a matter of choosing someone or something to lay out directives in case such a circumstance is to take place. Mo...
According to IC & RC, Case Management is defined as, “activities intended to bring services, agencies, resources, or people together within a planned framework of action toward the achievement of established goals. It may involve liaison activities and collateral contacts” (Herdman, John W., 6th Edition). Case management is a concerted effort of various professionals in the human social services network that assess’, plans, implements, coordinates,