COLLABORATIVE CASE MANAGEMENT
A Peer-Reviewed Journal for Case Management and Transitions of Care Professionals I S S U E
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A P R I L
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ISSN
2328-448X
In This Issue:
Chronic Care Management and a Letter from our CEO
T H E O F F I C I A L P U B L I C AT I O N O F T H E A M E R I C A N C A S E M A N A G E M E N T A S S O C I AT I O N
ISSUE 73
COLLABORATIVE CASE MANAGEMENT
PUBLISHER L. Greg Cunningham, MHA CEO ACMA • Little Rock, AR lgcunningham@acmaweb.org
EDITORS Jon Vickers ACMA • Little Rock, AR jvickers@acmaweb.org Tina Richardson ACMA • Little Rock, AR trichardson@acmaweb.org
EDITORIAL BOARD
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Chronic Care Management Lisa Hogan, RN, BSN
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Assessing and Addressing Care Management Diane DiFiore, DNP, MHSA, RN, NEA-BC, ACM-RN
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The Patient Arrives in 25 Minutes Dani Hackner, MD, MBA; Marc Adler, MD; Stephen Crouch, MD; Grace Dotson, RN; Lisa Flynn, MD; Robert Grant, MD; Paula Lenhart, RN; Ariana Peters, DO
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Decreasing Denials Together: A Lean Transformation Marcy Adelman, MSN, RN, ACM RN; Jean Chandler-Robledo, BSN, RN, BHA, CCM; Merlynda De Lira, MBA, MSN, RN, CCM, IQCI; Lupita Mora, MBA, RN
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Did You Know? Case Management—The Healing Effects of Nature “Case management in hospital and health care systems is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The case management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of case management include the achievement of optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s right to self-determination.” Approved by ACMA membership, November 2002
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Joan Brueggeman, RN, BSN, ACM-RN Director of Care Coordination and Utilization Management Services Gundersen Health System | La Crosse, WI Todd McClure Cook, MSW, MBA, EdD, FABQAURP, FABC, CHCQM, ACM-SW Vice President, Integrated Care Management Sharp HealthCare | San Diego, CA Diane DiFiore, DNP, MHSA, RN, NEA-BC Beaumont Health Director, Care Management Development and Education Beaumont Service Center | Southfield, MI Scott Ferguson, MSW, LCSW, ACM Director of Care Transitions and Population Health Mount Sinai St. Luke’s Hospital | New York, NY Dani Hackner, MD, MBA Pulmonary / Critical Care Medicine Chief Clinical Officer & Goodspeed Chair for Quality and Safety Southcoast Hospitals Group Southeastern Massachusetts – Fall River, New Bedford, Wareham Brenda Luther, PhD, RN Associate Professor NEPQR Program Liaison Specialty Track Director, Care Management University of Utah College of Nursing Salt Lake City, UT Ariana Peters Patnode, DO, FACOI, FHM Consultant, Hospital Internal Medicine; Physician Advisor Mayo Clinic | Phoenix, AZ Jessica Snoots, LMSW, ACM-SW Care Transitions Social Worker Frederick Health | Frederick, MD Article Submission Guidelines: Article proposals may be submitted to trichardson@ acmaweb.org in one of the following formats: completed article/manuscript, article abstract or article proposal. Submissions should include three learning objectives for your proposed article; outcomes information as applicable to the model/ program/intervention described in the article; author(s) bio information: name, contact information, organization, position, education/credentials; and statistical data and outcomes (including p-values) whenever applicable. All article submissions are reviewed and published at the approval of the Editorial Board. Collaborative Case Management is a peer-reviewed journal published quarterly by the American Case Management Association (ACMA) 11701 West 36th Street, Little Rock, AR 72211 Telephone: 501-907-ACMA (2262). Subscription is a benefit of membership in ACMA. Memberships are available at $135 per year. Student membership is open to individuals enrolled in a full-time academic program at $60 per year. More detail about membership categories is available at the ACMA website, www.acmaweb.org or by calling 501-907-2262. Photocopying: No part of this publication may be reproduced in any form or incorporated into any information retrieval system without the written permission of the copyright owner. For reprint permission, please contact ACMA, 11701 West 36th Street, Little Rock, AR 72211. The statements and opinions contained in the articles of Collaborative Case Management are solely those of the individual authors and contributors and not of the American Case Management Association. The Publisher and Editor disclaim responsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements. Copyright © 2020. American Case Management Association. All rights reserved.
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COLLABORATIVE CASE MANAGEMENT | ACMAWEB.ORG
Letter from the CEO This letter was sent to all ACMA Members on March 20, 2020.
D
ear ACMA Members,
Thank You. The work our members are doing, and will continue to do, throughout the Coronavirus situation is admirable and worthy of recognition. I have heard many stories of the uncharted territory and nuances added to your existing work. While this is an unprecedented event, we can take solace in one fact. Case Managers and Transitions of Care professionals know our infection control protocols. We know how to keep people safe, and we know how to navigate those we serve through the changing landscape of healthcare. Many of you have been pulled into different roles, filling gaps where your hospital systems and your communities need you. Others have remained in your current departments, dealing with higher caseloads with fewer case managers. While others are busy interpreting and implementing new and changing guidelines from federal, state and local levels. I commend all of you on your dedication to the patients and families we serve. This crisis especially impacts the populations that need us the most; the elderly, patients with multiple comorbidities and those transferring in and out of various settings. You are making a difference, as you always have. Like many other organizations across the world, ACMA has felt the financial impact of our social distancing initiatives. Our National and chapter conferences require a huge amount of planning, resources and capital, many of which are put in place years in advance. Rest assured, we are working hard to continue to provide you with education and networking opportunities now and in the future. With your support, we will come out on the other side as a stronger association. I also want to thank ACMA’s National Board, Chapter Boards and our National Staff for providing our membership with difficult risk mitigating decisions, timely regulatory updates, continuing to implement chapter conferences as late as mid-March such as in South Carolina, cancelling our national conference and rescheduling of chapter conferences previously scheduled for May and now evaluating those currently scheduled in June. It is a difficult time, but we are of hearty stock – I am proud to work with this group of professionals and need you to know that what you do does not go unnoticed. Our thoughts are with all communities impacted by the coronavirus. Lastly, I will share something I received yesterday that has been widely distributed during past crises. Fred Rogers (1928-2003) stated: “When I was a boy and I would see scary things in the news, my mother would say to me, ‘Look for the helpers. You will always find people who are helping.’ To this day, especially in times of ‘disaster,’ I remember my mother’s words and I am always comforted by realizing that there are still so many helpers—so many caring people in this world.” Case Management and Transitions of Care professionals are HELPERS. The desire to help others – the reason most of us chose healthcare as a profession – resonates among us. Please know that ACMA stands with you.
This crisis especially impacts the populations that need us the most; the elderly, patients with multiple comorbidities and those transferring in and out of various settings. You are making a difference, as you always have.
Warmest Regards,
L. Greg Cunningham ACMA CEO and Founder
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COLLABORATIVE CASE MANAGEMENT | ACMAWEB.ORG
Chronic Care Management Lisa Hogan, RN, BSN Frederick Health is a Maryland based community hospital with 233 licensed beds. With nearly 2,700 employees, Frederick Health is also one of Frederick County’s largest employers. The health system and hospital have achieved numerous accreditations and recognition (e.g., certified member of the MD Anderson Cancer Network) and are continuously focused on delivering quality care. The Chronic Care Management Program (CCMP) began in October 2016 as a way of helping Home Health Care (HHC) patients continue with remote patient monitoring and education post HHC discharge. Remote patient monitoring includes monitoring daily vitals and answers to disease-specific questions sent each day by the patient. Patients have a computer tablet, scale, BP cuff and pulse ox they use in their home every day for the nurses in the program to monitor and assess for any changes that could indicate a problem. The program has evolved over the last three years to include patient referrals from doctor offices, community agencies, hospitals, patients and families as well as an added medication management program 4
LEARNING OBJECTIVES 1. Evaluate how to identify appropriate patients for a chronic disease management program. 2. Differentiate the roles and responsibilities of staff involved in managing chronically ill patients. 3. Examine how remote patient monitoring can best be deployed to improve patient outcomes and assist patients in taking control of their care. INTRODUCTION The population of Frederick County has grown more than 40% in the last 25 years resulting in an additional 95,000 people in the hospital service area. With this growth, the health system was facing challenges in how to care for the chronically ill and aging population. With a multitude of new payment models in the state, Frederick Health Hospital was looking for innovative ways
to help reduce readmissions and emergency department (ED) visits. It was decided that the target population was patients who were currently in HHC services as well as patients who were discharged from HHC and in the community with limited resources. The long-term plan was to be active in the community, but the focus needed to be smaller for the pilot. The philosophy behind the program was simple: give people the resources they need—education, remote patient monitoring, weekly phone calls and home visits—and they will stay out of the hospital and reduce the ED visits. Frederick Health has its own HHC department who agreed to pilot the program to see if favorable results could be attained. The initial agreement was to continue having HHC patients on remote patient monitoring and identify those who would benefit from staying on monitoring after HHC discharged
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them to become part of CCMP. Patients who would benefit were those with a chronic disease condition such as CHF, COPD, diabetes, hypertension and those with frequent admissions to the hospital. The toughest selling point was that the program would be offered at no cost to the patient or the insurance companies. We were hoping the return on investment (ROI) for the program would off-set the cost of the equipment and staffing, improve patient satisfaction and increase involvement with their care. Time was spent researching other chronic disease management programs, care transition programs and best practices. Goals were developed for the program with the HHC director, a job description was written and research was discussed. The initial goals were to reduce 30-day readmissions to the hospital, decrease ER visits and increase patient compliance with managing their disease process. The key stakeholders identified were Frederick Health Hospital, HHC, doctors’ offices, patients and families. The stakeholders became engaged as the program targeted the highest utilizers of hospital resources as well as the challenging patients within the health system. Promised communication from the program to the stakeholders was another key element in the plan. It was important for the stakeholders to be informed of the progress and any challenges faced with the target population.
COLLABORATIVE CASE MANAGEMENT | ACMAWEB.ORG
“The program has proven its value with the money saved to the health system as well as feedback from the patients.”
capabilities for video conferencing and data collection. The goal was to increase to 100 patients with monitors. Options for remote patient monitoring were explored and the decision was made to partner with Health Recovery Solutions (HRS). This is a New Jersey based company that shares the same philosophy in patient care and wants the best possible outcomes for patients. In April 2017, CCMP received 75 monitors from HRS with the intention of increasing the monitoring with HHC discharged patients as well as possibly expanding the referral sources to other Frederick Health Hospital departments. The Frederick Health System chose to purchase the equipment and each complete unit was approximately $950. There is also a monthly data charge of $54.
of the program. Patients were skeptical in the beginning, as rarely is a program offered at no cost and they were not sure how it would work. The program went live in October 2016 when the first three patients were enrolled in the CCMP.
Referrals began to come in from the hospital Accountable Care Organization (ACO). These were not HHC patients, but patients identified in the community as needing extra assistance with education, weekly contact and monitoring of vital signs every day. We were beginning to see the benefits of the high touch we had with these
As the program grew, CCMP identified a need to have more monitors with increased
IMPLEMENTATION Frederick Health HHC had 30 monitors in stock with an average of 20-25 in use at one time. With our objectives and goals set, the program was rolled out with the HHC staff. CCMP requested HHC clinicians’ help to identify patients who would benefit from monitoring. This included setting up the equipment as described above, watching the readings as they came in every day and being in contact with the patient and family of any concerns. The staff was educated on the goals of the program which included their help in identifying patients who would be a fit for the program. A single staff member would set up the monitors, train the patient and family on how to use the equipment and introduce the CCMP patient for post discharge if needed. The key with the training was to make certain the patient and family were comfortable with using the equipment, had contact information for who to call with concerns and understood the specific reason they were asked to be part
Kathy Adams and Tiffany Rupp are holding one of the monitors used by Frederick Health’s Chronic Care Management Program.
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patients as well as the importance of a personal relationships with them and their families. In May 2018, the hospital system purchased more monitors to bring the total to 105. An additional RN was hired to help with the program. Patients were monitored seven days a week with weekly calls, monitor set-ups with the CCMP staff and home visits as needed for disease education and medication teaching. After operating and growing for over a year and a half, the need was seen to develop a way to measure the return on investment for the program and see if any changes had been made by offering the service to patients RETURN ON INVESTMENT The CCMP staff worked with data analysts in the hospital to determine a way to measure the impact the program was having in the community based on admissions and ED visits. The decision was made to use the ACO patients on the program and compare the Medicare claims from six months prior to being on the program and then six months after starting the program. This did not capture all the CCMP patients but a large portion of them. Once the numbers came out and the results showed a 41% reduction in ED visits and a 75% reduction in readmissions, the program began gaining more attention and discussions began on how to expand the program. More monitors were ordered and collaboration with HRS continued to improve our data and outcomes and how to measure accurately. CCMP staff began speaking with other community agencies to help identify more patients who would benefit from the program.
COLLABORATIVE CASE MANAGEMENT | ACMAWEB.ORG
and the work of the community agencies we partnered with to identify patients. It was a definite group effort with many case managers involved.
verification and develop a medication list for the home. The LPN makes subsequent visits weekly or bi-weekly to fill pill boxes, order refills and monitor for any changes or additions.
MEDICATION MANAGEMENT PROGRAM
In the first year, we were expecting 25-30 patients. However, there were almost 60 patients before the end of the first year. An additional LPN was hired to assist with the growth of patients and to help grow the program. Referrals have increased from doctors’ offices and community agencies as more patients are being identified as needing this type of assistance.
After looking at the community and some of the common reasons for readmission, it was evident medication management was a huge need for this patient population. Some of the issues stem from confusion about medications, lack of family support or even the inability to open bottles or fill pill boxes. CCMP applied for a community grant and was awarded funding for an LPN position to serve 25 patients a week with managing medications. Some of these patients were expected to come from community agencies such as the Department of Social Services, the Department of Aging and the Health Department. Adding an LPN to the program was a change in the original thought process of the program. Based on the evidence collected from the program and caring for patients, it became clear that medication management needed to play a role in helping to achieve our goals. As the program began, we received referrals from the expected sources but also from Meals on Wheels, AERS, doctors’ offices, hospitals and HHC. The concept was simple—help patients manage their medications and offer education and support. The CCMP RNs make the initial visit for medication reconciliation, send the medication list to all providers for
FIHN Referral No Yes
The chart to the right is the initial ROI data from the program. The estimated cost savings to the health system due to the decreased readmissions and ER visits was a little over $2 million. This cost savings was due to collaboration with CCMP, medical office case managers, hospital case managers 6
7
Telemonitor
THE PROGRAM’S CURRENT STANDING Fast forward to where CCMP is now. The program has three RNs, two LPNs, one CNA and 300 monitors. The team is involved in readmission meetings at the hospital to assist in identifying ways to help more people in the community and identify barriers to care as well as patients in need of disease education and monitoring.
20
Yes No
19 8
CCMP STAFF ROLES & RESPONSIBILITIES RN—Each RN is responsible for working the monitors every day. The load is split between HHC and CCMP patients. This allows for consistency with phone calls and relationship building with patients and families. The RNs make home visits to offer disease education, medication teaching and support as some patients transition to hospice services. LPN—Each LPN has a caseload of about 30 patients who are seen weekly or bi-weekly for pill fills, medication management and education as needed. CNA—This position is essential in helping the program function efficiently on a day-today basis. The CNA sets up and takes down monitors, troubleshoots issues with batteries and tablets, and helps with weekly calls. The CNA also makes companionship visits with some of the patients to address the issues of social isolation. Visits are made weekly and
Reason For DC Goals Met or Came Off Monitor
8
Patient Requested DC
8
Re-Admission Reason Not Specified
7 4
CCMP COST IMPACT 6 MONTH PRE CCMP START
6 MONTH POST CCMP START
%
PART A
$21,292
$14,956
-30.23%
PART B
$5,126
$4,872
-4.96%
TOTAL
$26,419
$19,729
-25.32%
ED VISIT PER BENEFICIARY
2.56%
1.52%
-40.58%
RE ADMIT PER BENEFICIARY
29.63%
7.41%
-40.58%
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CCMP PATIENTS
TOTAL
the purpose of the visit is to offer companionship and socialization for about 30 minutes per visit. Patients love and look forward to this part of the program.
COLLABORATIVE CASE MANAGEMENT | ACMAWEB.ORG
The charts to the right show the most recent data for the program as of January 2020. This was gathered by one of the data analysts from Frederick Health Hospital. The list of CCMP patients was provided and data gathered for 255 patients who met the criteria to be included. The criteria included patients who have been in the program for at least 6 months. The information in the charts was based on Medicare claims during the 6 months prior to being on the program and then claims during the 6 months after the program started. CCMP FUTURE Frederick Health Hospital and the CCMP program is looking forward to what the future holds for the program and our community. The hope is to engage more patients in the program to help the community be healthier and happier. The
PRE
POST
VARIANCE
ED ED VISITS VISITS
553
276
-277
-50%
30 30 DAY DAY RE-ADMIT RE-ADMIT
102
17
-85
-83%
PART PART A A EXPENSE EXPENSE
$8,252,311
$3,284,682
$ (4,967,630)
-60%
PART PART BB EXPENSE EXPENSE
$1,761,871
$1,631,823
$ (130,048)
-7%
METRIC
PRE
POST
ED ED VISITS VISITS
2.17
1.08
-1.09
-50%
30 30 DAY DAY RE-ADMIT RE-ADMIT
0.40
0.07
-0.33
-83%
PART PART A A EXPENSE EXPENSE
$32,362
$12,881
$ (19,481)
-60%
PART PART BB EXPENSE EXPENSE
$6,909
$6,399
$ (510)
-7%
VARIANCE
VARIANCE %
VARIANCE %
MEDICATION MANAGEMENT PATIENTS (subset of CCMP patients)
TOTAL
CCMP now gathers data twice a year on readmission rates for the inpatient and ED side of the health system. The program has proven its value with the money saved to the health system as well as feedback from the patients. Patients and families have reported increased compliance with medications, more involvement with their care and overall feelings of security knowing someone is monitoring them and calling them weekly.
METRIC
ED ED VISITS VISITS 30 30 DAY DAY RE-ADMIT RE-ADMIT
PER PATIENT
OUTCOMES
PER PATIENT
The whole team takes part in the set-up, maintenance and pick up of monitors as well as the weekly phone calls.
METRIC
PRE
POST
VARIANCE
VARIANCE %
65
39
-26
-40%
5
3
-2
-40%
PART PART A A EXPENSE EXPENSE
$1,154,035
$466,477
$ (687,558)
-60%
PART PART BB EXPENSE EXPENSE
$269,364
$344,827
$ 75,463
-28%
METRIC
PRE
POST
ED ED VISITS VISITS
1.71
1.03
-0.68
-40%
30 30 DAY DAY RE-ADMIT RE-ADMIT
0.13
0.08
-0.05
-40%
PART PART A A EXPENSE EXPENSE
$30,369
$12,276
$ (18,094)
-60%
PART PART BB EXPENSE EXPENSE
$7,089
$9,074
$ 1,986
-28%
plan is to expand the medication management program to reach more people. Video conferencing with the remote patient monitoring is also something that will be utilized more in the upcoming year. CCMP feels the largest component of the success of the program is the personal
VARIANCE
VARIANCE %
relationships that are built with patients and families. It is important to build those relationships to gain trust and confidence with the patients and families to engage them in their care. Spending time with patients and making them feel valued and special is what is most important. ABOUT THE AUTHOR Lisa Hogan, RN, BSN, is the team leader of the Chronic Care Management Program at Frederick Health Hospital. She has developed the program from the beginning and works with a team of clinicians who make a difference in the community every day. Lisa has been an RN for 33 years and worked in many areas of the healthcare system. She takes great pride in the program and working with patients and families in the community to achieve great outcomes for the hospital system and most importantly great outcomes for the patients and families served. The Chronic Care Management Program team, left to right, Kim McCormick, Angela Kombo, Tiffany Rupp, Lisa Hogan and Christine Kieti.
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COLLABORATIVE CASE MANAGEMENT | ACMAWEB.ORG
Assessing and Addressing Care Management Diane DiFiore, DNP, MHSA, RN, NEA-BC, ACM-RN Healthcare systems in the United States have evolved at a rapid pace over the past 30 years. During that time, the introduction and establishment of Title XVIII and Title 1 XIX , Diagnosis Related Groupings, ICD/ CPT codes and the Affordable Care Act have become an important part of the U.S. healthcare system. Compounding this is the detailed analysis each patient case requires to determine payer approval for inpatient admission and regulatory adherence. Length of stay, readmissions, hours in observation, delivery of notices to patients and auditing risks all fall under the purview of concerns within care management. Beaumont Health is a not-for-profit healthcare organization formed in September 2014 as a combination of three formerly existing healthcare organizations in southeastern Michigan. The company has a total net revenue of $4.7 billion (2019) and consists of eight hospitals with a combined total of 3,429 beds, 145 outpatient sites, nearly 5,000 physicians, 10,000 nurses, 38,000 employees and 3,500 volunteers. 8
LEARNING OBJECTIVES 1. Identify education and training deficits within the eight Beaumont Health Care Management Departments. 2. Establish educational goals to elevate and promote the education and development of the care management teams. 3. Design a standardized method of onboarding, competency training and certification opportunities for care management employees. Challenges Beaumont Health faced within the eight hospitals’ care management departments are not only the external complexities of navigating within the healthcare and payer systems but also the internal variation of roles and responsibilities among care managers, social workers, utilization reviewers and support staff across the system. Does the care management team truly understand the “why” behind what they do, what the payer is requiring, and how they balance being a patient advocate and a fiscally responsible member of the healthcare system?
These valid questions needed attention in order to best support the priorities of level setting education and competency among the eight care management departments. The intricacies of care management functions, the concerns regarding role variation across sites, and the lack of foundational understanding of what the care management staff does and why, required an intensive assessment. Care management had been locally operated at each of the eight acute care sites with no coordination from a central corporate model. The corporate care management department was established in April of 2018. Beaumont’s corporate care management department believed it was vital for the organization to have both a centralized and decentralized approach for orientation in order to motivate and retain employees, decrease turnover, increase productivity, improve staff morale, facilitate learning and reduce anxiety of new employees (Ragsdale & Mueller, 2005). Decentralized orientation has existed at the sites in various forms (i.e., use of a checklist, preceptor, observation,
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etc.) however no centralized program was in place. The need for standardized education with our staff and leaders (current and new), how we onboard, and how we maintain levels of competency were identified as priorities. This goal and priorities soon became a reality. The endeavor of creating a customized central approach to orientation was a threemonth journey. The main goal within corporate care management was to raise the standard for training and education within the care management division. This goal had a multipronged approach: corporate onboarding, competency training and certification. Implementing a corporate onboarding program, establishing an educational competency program and promoting certifications elevated the standard for the care management team. This comprehensive approach supported the foundation of understanding the complex world of care management, payers and regulations, to name a few. While doing site visits at each of the eight hospital care management departments, some staff members expressed a novice understanding of basic concepts within care management even though they may have possessed four to five years of experience. Common themes from all sites was a desire for more information, education and training about the multifaceted healthcare scope and the need to be kept updated about rapidly changing practices. Historically, sites provided information based on past practice and “how things have been done.” This discovery demonstrated that years of experience in this field did not equate to expertise and competence in the area. Benner (n.d.) explains the concept of novice to expert as a combination of strong educational foundation and personal experiences. Benner goes on to describe that oftentimes a nurse will “know how” without “knowing that.” Our goal addressed building their level of expertise and helping each participant gain more of “knowing that” through formal educational support.
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“The intricacies of care management functions, the concerns regarding role variation across sites, and the lack of foundational understanding of what the care management staff does and why, required an intensive assessment.”
CORPORATE ONBOARDING Utilizing various key stakeholders and teams was a priority. Meeting with each of the eight sites care management teams and leaders fostered more discussion about the goal of enhanced and expanded training and education and was positively received. A draft of the onboarding slides was presented to the
care management leadership group and staff to ascertain feedback on content and flow. Based on the groups’ feedback, the corporate onboarding program progressed into two, four-hour sessions offered each month for new hires within the care management department. Onboarding Part 1 addresses the history and evolution of healthcare, national and local care management standards, the patient experience and communication techniques. Onboarding Part 2 addresses the compliance and regulatory requirements and transitions of care. Internal experts were utilized as subject matter experts in providing content information about the revenue cycle, financial clearance, motivational interviewing, patient choice and the patient experience. All new and current care management leaders, care coordinators, social workers, utilization managers, data analysts and support staff are invited to attend care management onboarding part 1 and 2 classes. These classes are taught by the care management educator and site leaders utilizing an interactive approach with videos, case scenarios and open discussion. At the beginning of the class, each attendee takes a pre-quiz to assess the participant’s baseline knowledge. At the conclusion of the session, the same questions are repeated in the post-quiz to determine comprehension and effective presentation of the material. Spread throughout the two-part sessions are videos of Beaumont Care Management staff describing their role and the work they do. This adds a personal touch to help recognize the important work of the care management team. Following each session, the attendee completes an evaluation rating the value of the material and any additional comments. This feedback is used to update the training materials. Starting in April 2019, a 60-day post-onboarding survey has been sent electronically to all attendees who attended class two months prior to assess for application and value of the material. Based on class evaluation and 60-day follow up survey 9
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feedback, the onboarding presentations have been regularly updated. Another layer of corporate orientation requires that all new care management leaders meet with the corporate care management team. In addition to attending onboarding part 1 and 2 classes, new leaders learn care management dashboards, electronic medical record navigation and reports, and the content within the care management website. They are “buddied” with a leader colleague at another care management acute care site for more training and observation and utilize an extensive checklist for tracking purposes. After 90 days, the new leader meets once more with the corporate care management team to review and assess additional educational needs and support.
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modules were chosen by each site based on priorities of their team. Physician Advisors are required to complete all modules for baseline competence.
Additionally, a certification review course, hosted by ACMA, was provided in the fall of 2019 to continue to improve and enhance care management service delivery and
ABOUT THE AUTHOR Diane DiFiore, DNP, MHSA, RN, NEA-BC, ACM, is Director of Care Management Development and Education at Beaumont Health.
ONGOING EDUCATION THROUGH COMPETENCY AND CERTIFICATION A strategy in meeting the continuing educational needs of the entire care management division is through ongoing competency training. Compass is the method of choice for the next three years. In April of 2019, the teams began to utilize the Compass modules for further validation of learning. Five required modules were assigned for care management, social work and utilization review staff to complete. Three modules required for all sites to complete were Patient Status and Level of Care, Overview of Resource Management, and ACO Models, Quality Measures and Bundled Payments. The remaining two
has been assessed through the onboarding evaluation feedback (12-month average is 98%). Comments shared within the evaluations have been very positive, noting an increase in the participants’ knowledge of compliance and regulations, communication techniques and scope of practice. A follow-up survey is sent to attendees 60-day post onboarding classes to assess for content application in daily work. Results indicated that 70% to 80% of the respondents rate the use of content as extremely to somewhat helpful in their day-to-day work. Future outcomes data will be measured through employee satisfaction, patient satisfaction and employee turnover.
FOOTNOTES
professionalism. According to the National Hospital Case Management Survey, 47 percent of Accredited Case Management (ACM) credentialed professionals indicate that certification has increased their professional knowledge and competency (Allen, 2019). Since the launch of the new onboarding program in January of 2019, outcomes data
1. Title XVIII established regulations for the Medicare program, which guarantees access to health insurance for all Americans, aged 65 and older, younger people with specific disabilities, and individuals with end-stage renal disease. Title XIX established regulations for the Medicaid program, which provides funding for medical and health-related services for persons with limited income: mainly covering pregnant women, adults with dependents, people with disabilities and the elderly. Retrieved from https://governmentprograms.laws.com/title-xviii-and-xix-of-thesocial-security-act
REFERENCES 1. Allen, M. Hospital system encourages and supports certification in case management. (March 2019). Collaborative Case Management. 68, 21. 2. Patricia Benner novice to expert-Nursing theorist (n.d.). Retrieved from http:// nursing-theory.org/nursing-theorists/ Patricia-Benner.php 3. Ragsdale, M., & Mueller, J. (2005). Plan, do, study, act model to improve an orientation program. Journal of Nursing Care Quality, 20(3), 268–272. Retrieved from http:// journals.lww.com/jncqjournal/ Abstract/2005/07000/Plan,_Do,_Study,_ Act_Model_to_Improve_an.13.aspx
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PUBLIC POLICY A D V O C AT I N G
F O R
C A S E
M A N A G E M E N T
Working On Your Behalf
In early March, members from the ACMA National Board of Directors and Public Policy Committee flew into Washington D.C. to meet with national lawmakers on behalf of the case management and transitions of care profession. The focus was to advocate for the Improving Access to Medicare Coverage Act, to share findings from the ACMA Case Management Report and to discuss issues that are important to our members and the patients they serve. Read more about public policy and advocacy at acmaweb.org/advocacy.
Reach case managers who influence purchasing decisions for patients regarding services provided across the continuum of care. To reserve advertising space, contact:
Becky Nations
bnations@acmaweb.org • 501-907-2262
ACM Certification Review Workshop
TWO-PART WEBINAR SERIES Part 1: Saturday, May 9 Part 2: Saturday, May 16 11
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GRAND ROUNDS
The Patient Arrives in 25 Minutes Dani Hackner, MD, MBA; Marc Adler, MD; Stephen Crouch, MD; Grace Dotson, RN; Lisa Flynn, MD; Robert Grant, MD; Paula Lenhart, RN; Ariana Peters, DO Editors Note: This article was submitted on March 10, 2020. The following is a scenario for discussion. It is based on several scenarios encountered by the participants. The contributors include members of the Association of Physician Leadership in Care Management (APLCM) Board as well as case management leaders. LEARNING OBJECTIVES 1. Understand initial steps that need to be made quickly in these types of scenarios for everything to run as smoothly as possible. 2. Describe the differences in healthcare planning and response to weather, trauma and infectious disease-related scenarios. 3. List the variety of technology challenges that can be involved in these types of scenarios and how those challenges can be resolved. DISCUSSION SCENARIO On June 1, at 1:20 PM, your hospital leadership team is called to meet in the board room. You are the lead for physician advising, and you expect it is related to the hospital Code Red (status of high patient volume and diversion of non-trauma patients). The Chief Executive 12
Officer, Chief Clinical Officer, Chief Nursing Officer, Chief Operating Officer and Director of Case Management await the Director of Disaster Management, Kisha Atwood. Kisha enters the room and briefs the group. At 12:30 PM, a passenger plane touched down from South America. During the rough landing, a passenger not wearing a seatbelt had head trauma and transient loss of consciousness. The patient is being transported to your hospital. In addition, the captain radios that additional patients in the plane may have respiratory ailments. As of 11 AM today, the country of origin for the plane has been placed on the high concern list by the CDC for the prevalence of a novel virus with a high mortality. As the nearest hospital and only Level 1 Trauma Center, you must make plans for the trauma patient as well as triage of potentially infectious patients. Per the CDC, the virus is spread via a respiratory or contact route and leads to pneumonia and ARDS. The trauma patient is expected within 25 minutes.
WHAT ARE THE INITIAL STEPS NEEDED? Dr. Hackner: In a situation like this it is important to activate the Hospital Emergency Incident Command Center. This may involve individuals listed above but also some key additional participants such as human resources, medical staff office, lead for materials management, communications officer and leads for ED and trauma. In this scenario, the group needs to immediately notify trauma, neurosurgery, nursing, emergency services and the operating room in order to prepare for a potentially infectious patient who may well require appropriate isolation, materials and a careful path through the hospital so as not to expose others.
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Dr. Adler: My first calls would be to reach out to the people first seeing the trauma patient directly, including the nursing directors, emergency medical directors and trauma surgeons. I would let them know that the patient is coming and our concerns about isolation and exposure. When we do convene HEICS, we should also make sure that the Chief of Respiratory Services, the Director of Security, Chiefs of Medicine, Surgery and Trauma, and Chief of Marketing are also present. Dr. Crouch: We would set up a line of communication with the Department of Public Health. It’s important to make sure that the proper relationship is in place as the hospital may be in a different jurisdiction than the airport. While the current priority is one trauma patient, we expect a system-wide EMS notification related to the potentially infectious patients who may need care or home quarantine. You fully expect the Department of Public Health to notify all hospitals that ‘no-one is on divert.’ Anticipating the arrival of the other passengers, I call the Director of Infection Prevention.
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Dr. Peters: I would recommend we mobilize a number of staff including the physician advisor, case managers and a hospitalist to assist in dispositioning patients. We applied this approach during the Ebola scare to assure that we had space and staff to deliver care to patients in the appropriate isolation space. In H1N1, we used non-acute care areas to stage transfers to non-acute environments. Auditoriums became discharge lounges and greatly assisted in isolating patients needing care in acute areas.
Dr. Crouch: It is essential that the ED, post-surgical recovery and the hospitalists begin decompressing immediately. The physician advisor, aware of the patients not meeting medical necessity, near discharge or in observation, can be highly effective in aiding the process.
Dr. Hackner: In Hurricane Harvey, we set up an emergency credentialing process to bring in providers both in-state and out-of-state because hospital staff were in such short supply. Nurses, hospitalists and intensivists were staying beyond their shifts. There was a critical need for ‘headsup’ leadership, and it was incredibly helpful to have physician advisors and case managers able to address a variety of care gaps. When coordination issues arose, it was especially helpful to have leaders ‘out of count.’ These leaders gave more bandwidth to CEOs, CNOs and COOs. Dr. Peters: Issues such as parking and traffic flow can be key to success. How will a planefull of patients arrive and be triaged, assessed and isolated? A staging area is key. Weather permitting, an outdoor staging area can reduce the risk of a room being down one to two hours after airborne isolation and terminal cleaning.
Dr. Adler: We activate our automated call tree. It allows automatic notification of key staff, assuring that we do not omit an important stakeholder or take up too much time on notifications. Dr. Grant: Our experience in New York with the Port Authority responsible for all airport traumas is that there are already contacts in place with specific hospitals. With each new experience such as Ebola, the contacts and workflows have been updated. A key element is having isolated, segmented rooms.
a mass casualty or a mass infectious disease mobilization. We saw this used effectively in 9/11.
Dr. Adler: One of the challenges is getting nursing staff immediately. In addition to nurse case managers, unit managers, nursing informaticists, UR nurses and other licensed personnel can step into direct clinical roles. Likewise, so can physician advisors. We need to think whether they are needed in direct clinical care or a case manager/physician advisor role. Dr. Grant: There needs to be a mechanism for deputizing leaders and rapid credentialing individuals in either
Ms. Lenhart: Planning ahead for such patient traffic flow is key. During an infectious disaster, like a weather disaster, it is important to consider paths that are risky for patient travel and paths that are preferred. In Tropical Storm Allison in 2001, which caused 8.5 billion of damage to Houston, the flooding of basement generators created challenges for patient transport. Close planning between Disaster Management and Case Management enabled plan B that allowed safe evacuation of an entire 800 bed medical center. Dr. Grant: During 9/11, we received transfers to our burn unit. We took in critically ill patients. However, we saw over 150 at Cornell and Columbia who were sent away without serious disease. The busiest service was ophthalmology with corneal abrasions, needing assessment and eye washes. We need to be prepared 13
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for one service, such as respiratory, to be overwhelmed. In the best disaster management, you need to be prepared for a variety of eventualities, whether it is the ACS Triage of shooting victims or the CDC triage of infectious patients.
after 12 hours on-shift. We had to empower respiratory techs to intubate and stretched all our resources in that austere environment.
Dr. Adler: For SARS and Ebola, a key to success was doing several tabletop exercises.
Ms. Lenhart: It is essential to consider the types of disasters you may encounter and how you plan to use staff and other resources. Weather disasters have a predictable early phase, initial damage and then late phase when access becomes possible and the ill and walking well arrive. The most difficult periods are often a week or two after the initial disaster when staff are exhausted. Disasters related to trauma and violence such as shootings are unpredictable and sudden. They force a sudden mobilization and can rapidly overwhelm a single service such as trauma. Scaling up is the biggest. Disasters related to infectious outbreaks tend to have slowly accumulating patients which may incrementally overwhelm resources at a hospital or region. Annual flu can be considered in this category. Each requires different planning.
Dr. Adler: In infectious outbreaks, it is important to limit staff. Choose a team, limit their exposure to the source.
Dr. Hackner: Our experience in Hurricane Harvey in 2017 was helped greatly by having two prior floods the two years before (the Memorial Day flood of 2015 and the Tax Day Flood of 2016). With each response, our preparation became more effective. However, the most important steps were the large-scale simulations of hospital evacuation and systemwide triage. There were three important keys. First, centralizing EMS transport and EMS communication enabled us to touch base regularly every 2 hours. This facilitated early triage of critical patients and late triage of discharge patients. Ambulances for more acute patients, buses for ambulatory patients and prepositioned fuel were key to smooth flow. All was simulated in our drills ahead of time. Our AVP for Care Management, Paula Lenhart, managed the EMS contract and the lead physician for Care Management managed the EMS communications. Second, by developing a systemwide bed triage tool, we were able to assess capacity at all sites for evacuation of a community hospital when the Brazos River neared breach. We were able to smoothly evacuate that hospital and place the patients safely. Our leads for case management and physician advising managed the triage and placement tool. Thirdly, we were able to use the experience from prior storms such as Allison to develop a regionwide dialysis collaboration to identify chairs throughout the region, regardless of the original dialysis vendor. This was facilitated by the Chief Clinical Officer and handed off to the VP of Care Management. A dialysis case manager was assigned to thrice daily coordination calls with the two large vendors. Vendors that had been operating heads-down and sometimes even center-by-center were now urged to collaborate. This real-time collaboration with dialysis vendors was applied the following year in Florida with their extensive flooding. 14
Ms. Lenhart: During these situations, the emerging needs are frequently predictable. We arrived at the dialysis collaboration by predicting the need based on days of flooding and roads opening up. Likewise, during an infectious outbreak, you can work with your public health and epidemiology staff to model the expected needs and plan accordingly. Ms. Dotson: In response to 9/11, the center where I was working triaged patients using paper lists. Nevertheless, we created plans A, B and C for each. As we reviewed the list, the question was asked, who could be discharged earlier than anticipated and can we provide resources to set up a hospital-at-home environment. Could some patients move to a hotel room or shelter with services? We identified which patients could be transferred to community hospitals. The transfer center staff worked closely with case management. Each patient was assigned an updated acuity score during the day. We also reached out to nursing homes to allow exceptions to their typical rules for admission. Dr. Grant: For this situation, in addition to managing patient volume, we may also need to be calling additional staff to come in and holding in-house staff from leaving at end of shift. Some may require sleeping quarters. Dr. Flynn: Our experience in Iraq with mass casualty tents is that no one was available
HOW DO YOU SEE THE ROLE OF CARE MANAGEMENT LEADERS IN THESE TYPES OF DISASTERS? Ms. Lenhart: Case management and social work have unique roles in these situations including facilitating discharge, identifying patients for reallocation/reassignment, and crucially family communication. In some of these disasters, managing the trauma to families and community can be crucial. In Harvey, for instance, one of the major challenges was the situation posed by homeless individuals with nowhere to go during massive flooding. Some of these perennially and newly homeless began overwhelming some common areas in the hospital. In other cases, individuals seeming safe for discharge medically were unable to care for themselves due to serious emotional trauma. Ms. Dotson: After a school bus incident in October of 1993, we set up a family reunification room. It was a calm, private place where parents were sheltered from the media. Designated runners were dispatched between PICU, OR or ED to provide clinical updates to parents. Social work, pastoral care and patient relations worked together to provide emotional and spiritual support to parents and to assure
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accurate recording of events. We recorded time, name and role for every room entry as well as nicknames, the bus the injured child was riding, etc. Special attention was placed to matching children and parents and locating them rapidly in collaboration with PR, security, state police and the clinical team. Walkie talkies for staff and cellular phones were used to reunify the Director of Social Work or Case Management. This typically takes place twice daily. In a disaster such as this scenario, one can imagine the need for more frequent rounding. Dr. Peters: In our system, physician advisors are part of a specific department. We do not have the luxury of peeling off those FTEs for central efforts. Ms. Dotson: In response to a surge of incoming patients due to a mass casualty incident, hospital leaders may implement a strategy known as reverse triage. This military term refers to treating those who are not seriously injured first to allow them to return to the battlefield (Wiseman, Ellenbogen and Shaffrey, 2002). Applying this concept to the civilian medical model, the least sick will be considered for early discharge. Reverse triage during a disaster is consistent with good care “taking sufficient and appropriate care to avoid harm” with the intent to “do the greater good for the greatest number” (Beauchamp and Childress, 2001, P. 118). The concept has been studied and may save lives by prioritizing ED patients over discharging patients for acute beds (Eur J Emerg Med. 2016 Aug;23(4):240-247).
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In disasters such as these, one should consider a triage algorithm such as the NYU ED Triage Algorithm (Billings). The Billings algorithm classifies ED utilization into (1) non-emergent, (2) emergent/primary care treatable, (3) emergent – ED care needed and preventable, (4) emergent 0r ED care needed and not preventable/avoidable. (Med Care. 2010 Jan; 48(1): 10.1097/MLR.0b013e3181bd49ad. doi: 10.1097/MLR.0b013e3181bd49ad).
Finally, for relevant material on COVID-19, Ebola and other pathogens, visit the cdc.gov including job aids on donning and doffing personal protective equipment.
Dr. Hackner: We have increasing evidence in the literature that reverse triage scoring systems can predict likelihood of mortality and contribute to decompression for needed surge space. (Indian J Crit Care Med. 2018 Aug; 22(8): 575–579, JAMA Pediatr. 2017 Apr 3;171(4): e164829. doi: 10.1001/ jamapediatrics.2016.4829. Epub 2017 Apr 3, Emerg Med J. 2012 Feb;29(2):160-2. doi: 10.1136/emj.2010.098087. Epub 2010 Oct 28.).
Marc Adler, MD, MBA, FACP, CHCQM, APLCM President-Elect, is a physician advisor in internal medicine, and medical director/physician advisor at NYU Langone Medical Center.
An excellent resource on Critical Care Surge Capacity Logistics is the Chest supplement (Surge Capacity Logistics. October 2014Volume 146, Issue4, Supplement, Pages e17S–e43S DOI: https://doi.org/10.1378/ chest.14-0734). A strong course available to senior health and municipal officials is the Crisis Leadership and Decision-Making seminar offered by Texas A&M Engineering (https:// teex.org/wp-content/uploads/MGT-340Crisis-Leadership.pdf). For a first-person experience of disaster response in austere conditions, read: “Lessons from the Gulf: Hurricane Harvey, Disaster Management and First Planners” (Collaborative Case Management, 66, Aug 2018, pp 3-8).
ABOUT THE CONTRIBUTORS Dani Hackner, MD, MBA, APLCM Board Member, is pulmonary/critical care, chief clinical officer of Southcoast Health/SHG in Massachusetts.
Stephen Crouch, MD, FACEP, APLCM Board Member, is medical director of care management at Advocate Aurora Health System. Grace Dotson, RN, BSN, MHA, CMAC, Executive Director of Clinical Integrated Care Services for Southcoast Health Systems in Massachusetts. Lisa Flynn, MD, FACS, CHCQM, APLCM Board Member, is Executive of Clinical Innovation at Tenet Healthcare.
Robert Grant, MD, MSc, FACS, APLCM President, is PA and Chairman Utilization Management Committee at New York Presbyterian. Paula Lenhart, RNC-NIC, MSN, CNS, ACM-RN, FABC, Care Management Leader. Ariana Peters, DO, FACOI, FHM, APLCM Board Member, is a physician advisor and hospitalist/instructor in medicine at the Mayo Clinic in Phoenix, Arizona.
SAVE THE DATE!
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Decreasing Denials Together: A Lean Transformation Marcy Adelman, MSN, RN, ACM RN; Jean Chandler-Robledo, BSN, RN, BHA, CCM; Merlynda De Lira, MBA, MSN, RN, CCM, IQCI; Lupita Mora, MBA, RN How can the Utilization Review Case Manager see the approved surgical procedure authorization? Attempting to answer this seemingly simple question led San Diego’s largest non-profit healthcare system to launch a lean transformation project which decreased denials by creating standard work, establishing metrics and optimizing communication with the Revenue Cycle departments. So, how can case management see the preauthorization for scheduled surgeries? When a group was brought together as a Black Belt project to answer this question, it was learned that the system lacked standardization. With four acute care hospitals, each hospital had their own set of processes and definitions. Frequently, the communication workflow consisted of email strings. The goal of the project became to create standard work, establish metrics and optimize the communication flow for the utilization review process performed by case management. 16
LEARNING OBJECTIVES 1. Explain why the communication process between Revenue Cycle and Utilization Management/Case Management departments is key. 2. Identify challenges that were critical to the success of the project. 3. Describe how optimizing communication and decreasing denials helps sustain a responsible review process and demonstrates a strong commitment by all teams to the financial health of the system. PROJECT CHALLENGES The case management service line exists in a mode of continuous transformation and quality improvement initiatives. To develop a responsible sustainable case management model and structure, optimizing the communication process between Revenue Cycle and Utilization Management/Case Management departments was key. As the lean project began to look at the frontline processes it was acknowledged that
the software solutions used by each team were not compatible. The system’s inability to transfer data properly created defects, and there was no process established to address fallouts or close loops. Multiple emails to address issues and provide workflow became noise over time. Customized work processes at each entity contributed to defects and rework for both Case Management and Revenue Cycle departments. There was low accountability for role responsibilities and an inability to measure performance. Missing or invalid insurance contact information created process delays. There were also frequent changes in team members and leaders throughout the project, and frustration from past projects delayed trust in team members. Challenges that were critical to the success of the project included timely initial payer notification and request for authorization, as well as request for payer contact information to send a timely utilization review sent to the payer. Case managers and the Revenue Cycle staff both needed access to authorization, including timely continued stay authorizations.
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used for comparison with 1,366 denials for controllable reasons. By 2018, the number of denials was down to 267 for the clinical year. Financially, this led to a reduction of nearly $10 million over 3 years.
The project was able to standardize the utilization process throughout the system, and standard work was developed for system usage and workflow. A strong relationA system black belt assisted with this ship was built between Case Management project, but no outside consultant was used. and the Revenue Cycle departments. ProOur belief is that a similar method could be cesses were put into place that allowed the used by any hospital or system to reduce case manager to see the payer notification denials and thereby increase revenue by and any existing pre-authorizations. A central repository for scanned authorization or denials is available CONTROLLABLE CLINICAL DENIALS for viewing by both Case ManNUMBER OF DENIED ACCOUNTS agement and the Revenue Cycle. A Payer Contract Grid provides 2019 Q3 186 visibility of each payer’s requirements and contact information 267 2018 as well as payer commitments. COLLABORATIVE EFFORTS CONTINUE In October of 2017, the system changed the case management software program from Allscripts to Cerner Acute Case Management. The teams once again came together to make sure that the process and standardization success was not lost in the change. Collaborative communication and an understanding of the need to be able to see key parts of each team’s workflow helped make the transition a smooth one.
Elect of the Southern California chapter of ACMA. She currently serves as the Director of Integrated Care Management at Sharp Memorial and Sharp Mary Birch Hospital for Women and Newborns. Marcy has a passion for helping case management team members learn resilience.
Jean Chandler-Robledo, BSN, RN, BHA, CCM, is the Manager of Integrated Care Management and Sharp Coronado Hospital. Jean received her RN at Indiana University, her BSN at Grand Canyon University and her BS in Healthcare Administration at Chapman University. Certified in Case Management since 1993, Jean received Manager of the Year from VITAS Hospice and Leader of the Year from Sharp 458 2017 Grossmont Hospital. Jean has been with Sharp healthcare for 12 1366 2016 years. She has experience in Medical/Surgical Nursing, 0 200 400 600 800 1000 1200 1400 1600 Psychiatric Nursing, Managed Care, and Hospice and Case Management including Director CONTROLLABLE DENIALS of Hospice Services. NET DOLLAR AMOUNT DENIED
Merlynda De Lira, MBA, MSN, RN, CCM, IQCI, received her BSN from Loma Linda $4,828,200 2018 University School of Nursing in 1997. In 2016, she obtained a dual $5,067,187 2017 master’s degree in Business Administration and Nursing, with Continued collaboration includes 2016 $13,669,494 a focus in health care a “soft” denial process which calls $0 $2 Mil $4 Mil $6 Mil $8 Mil $10 Mil $12 Mil $14 Mil $16 Mil administration from the University for immediate action when a of Phoenix. Merlynda brings 21 patient currently in the house is years of nursing experience, provided with a denial. There is a standardizing workflows, establishing including over 15 years of case management standardized process for peer-to-peer efforts metrics, and optimizing the communication experience within health plans, managed care when needed. The Case Management and flow between Case Management and Revenue organizations, and in the hospital setting. She Revenue Cycle departments meet with patients Cycle departments. is currently the Director of Integrated Care who are denied coverage, refuse repatriation Management at Sharp Grossmont Hospital, or are unwilling to discharge. Patients are In this challenging time when reimburseand leads 75 staff members in this 530-bed encouraged to reach out to the payer who is ment is decreasing and expenses are increasfacility. Merlynda’s passion is to assist in the denying payment for a continued stay. When ing, optimizing this communication and development of programs to educate and needed and appropriate, the Revenue Cycle decreasing denials help sustain a responsible promote the profession of case management and Case management departments work with review process and demonstrate a strong in the acute care setting. the patient to appeal to the state department commitment by all teams to the financial of managed healthcare or insurance. health of the system. Lupita Mora, MBA, RN, has been at METRICS OF SUCCESS Sharp HealthCare for almost 20 years. She ABOUT THE AUTHORS has served in leadership roles for the past The stated goal of the lean project was to Marcy Adelman, MSN, RN, ACM RN, decade and is a Lean Six Sigma green decrease denials due to a lack of untimely has been in healthcare for more than three belt. She currently serves as the Director of clinical reviews and ensure that 80% of all decades. She has served as Director of Case Integrated Care Management at Sharp acute care admissions will have the initial Management for three hospital systems in Chula Vista Medical Center and Birch Patrick utilization review performed within 24 hours the San Diego area and is the PresidentConvalescent Center. of admission. The year 2016 was the baseline
2019 Q3
$3,753,234
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Did You Know?
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The Healing Effects of Nature Did you know that being in nature, or just looking at scenes or listening to nature, reduces anger, fear, stress, anxiety and increases pleasant feelings, makes you smile, unwind and relax? Of course, you did! As a health professional you do know this, but are you doing it? During this unprecedented time in our lives where this global coronavirus pandemic is affecting us, our families, our businesses, our communities, and our way of life, remember to rejuvenate your mind and body and take care of yourself. Exposure to nature not only makes you feel better emotionally, it contributes to your physical well-being, reduces blood pressure, heart rate, muscle tension and the production of stress hormones. According to an article titled “11 Scientific Reasons Why Being in Nature is Relaxing” on mentalfloss.com, here are some ways being in nature is good for you n Vitamin D Helps Your Body Function More Efficiently n Natural Light Normalizes Your Sleep Schedule n Being in Nature Causes You to Unplug n A Natural Environment Helps You Center Your Mind n It Gives Your Brain the Downtime It Needs to Recharge n It Lowers Stress Hormone Levels n Fresh Air Improves Blood Pressure n Breathing is Your Body’s Built-In Stress Buster n Oxygen Affects Your Sense of Well-being n Bacteria in Soil Also Boosts Your Serotonin Levels Keeping CDC guidelines and social distancing in mind, get out in nature, breathe fresh air, take a hike, climb a mountain, walk through a field or by a stream, plant a tree, blow the fluffy whitetopped seeds off a dandelion and watch them fly away, smell the beautiful fragrance of roses, or just sit calmly for a bit in your back yard listening to the birds. If you can’t get out in nature, take some time to watch and listen to nature online. It’s amazing how it can renew your spirit.
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CERTIFICATION SERVICES
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The Accredited Case Manager (ACM) Certification was created specifically for Health Care Delivery System Case Management Professionals. ACM Certification tests case management knowledge that is shared by Registered Nurses (ACM-RN) and Social Work Case Managers (ACM-SW).
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Case Management Administrator Certification (CMAC) validates the competency of case management administrators, managers and aspiring leaders, and promotes professional practice standards. This level of expertise helps improve care transitions by ensuring a more robust discharge plan for patients to ensure length of stay reductions and readmissions. The CMAC credential is available to all professions.
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