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For Your Business or Department
Developing a Business Plan
Pricing the Market
Looking at the Competition
Networking and the Professional Community
The Business Community
Generating New Business
Hiring Additional Staff
Defining Success
Business Websites
CHAPTER 8
Home Care Case Management, Long-Term Care, and Healthcare Reform
Consumer Demand and Ambivalence
The Case Manager as a Pivotal Link
Cases in Profile
Ongoing Support at Home
Importance of Feedback and Communication
Payment Concerns
Tools to Help You Assess the Quality of Care You Are Receiving
Informing the Client
Level of Involvement
Importance of Ongoing Involvement
Changes in Long-Term Cases
Negotiating for Long-Term Care
Employing all Possible Resources
Long-Term Care of the Elderly
Implications of Long-Term Care for the Family
Implications of a Long-Term Case for the Case Manager
From Acute Care to Home Care: A Case History
CHAPTER 9
Pediatric Case Management
Challenges Facing Pediatric Case Managers
Achieving Quality Improvements in Pediatric Case Management
Medicaid and the Pediatric Patient
Levels of Pediatric Case Management
Children’s Hospitals
Immunizations
Caring for Children with Mental Health Problems
Benefits of Case Management
CHAPTER 10
Workers’ Compensation Case Management Overview
Benefits
Costs and Occurrence
Workers’ Compensation Case Management and Rehabilitation Management
Impact of the Affordable Care Act
Veterans’ Return to the Workforce
Mediating Workers’ Compensation Claims
Other Issues in Workers’ Compensation Case Management
Workers’ Compensation and Implications for Case Managers
Value-Based Health Care: Workers’ Compensation and Case Management
PART IV THE CASE MANAGEMENT PROFESSIONAL
CHAPTER 11
Legal Responsibilities of the Case Management Professional Malpractice
Other Legal Issues: Patient’s Bill of Rights and Patient Confidentiality
Medical Records, Electronic Health Records, and HITECH
The Right to Know versus the Need to Know
Disclosure Issues
Adequate Information
Contracts and Letters of Agreement
Legal Issues in Case Management
U.S. Legislation Relevant to Case Management
CHAPTER 12
Ethical Responsibilities of the Case Management Professional
Patient Rights and Case Manager Responsibilities
Ethics and Medical Errors
Codes of Ethical Conduct
Objectivity and Common Sense
Look to Your Resources
CHAPTER 13
Evidence-Based Practice for Case Managers: Data-Driven Decision Making
What Exactly Is Evidence-Based Practice?
Evidence-Based Practice for Case Managers
The Evidence
Case Management: Specific Evidence-Based Resources
Applying Evidence-Based Case Management
Conclusion
CHAPTER 14
Case Manager Credentialing and Organizational Accreditation
Certified Case Manager (CCM)
The CCM Exam
Before CCM, to the Wide Array of Credentials Now Available
Certified Professional in Healthcare Quality (CPHQ)
Concerns and Questions
CHAPTER 15
Reimbursement Resources and Challenges
Insurance Providers and Administrators
Basic Insurance and Administrative Company Players
Administrative and Customized Services
Employers and Case Managers Respond to Costs
CHAPTER 16
Healthcare Reimbursement: Private Sector or Employer Sector
Auto Insurance
Health Benefit Insurance: Employer-Sponsored or Private
Indemnity Plans
Group Medical Plans: HMOs, PPOs, and POS Plans
Disability Insurance Plans: Short Term and Long Term
Consumer-Driven Healthcare Plans
Diagnosis-Specific Benefits
Traditional Insurance versus Self-Funded Plans
Stop-Loss Insurance Plans
Viatical Settlements
Nontraditional Policies
Riders to Life Insurance Policies
Coordination of Benefits
CHAPTER 17
Healthcare Reimbursement: Public Sector
New Directions in Public Sector Case Management
Funding Sources for Public Sector Health Benefits
Economic Impact and Government Response
A Case Manager in the Public Sector
CMS Population Groups Challenge Managed Care Industry and Providers
Challenges for Case Managers
Remaining Complications
Nonmedical Challenges Influence Outcomes
Military (Active and Veteran) Case Management
Conclusion
CHAPTER 18
Working Effectively with Claims Departments: Case Managers in Consulting Roles
Claims Department Structure and Operations
Computerization
Claims Issues
Indicators for Case Management
The Case Manager as Consultant
Tracking Claims by Group
Tracking Claims by Individual Claims Histories
Moving into the Consultant Role
PART VI LEADERSHIP AND MANAGEMENT: MACROSYSTEMS
CHAPTER 19
Outcomes Management with Analysis of Financial and Quality
Assurance Reporting
Financial and Quality Assurance Reporting
Dollars and Health Care
Negotiating Skills
Nuances between Negotiating with Providers and Payers
Negotiating in a Managed Care Environment
Documenting Negotiated Arrangements
Cost–Benefit Analysis Reports
Cost–Benefit Analysis Summaries
Quality Assurance Programs
Explaining Difficult Situations
Feedback from Patients
Sharing Questionnaire Results
CHAPTER 20
New Strategies for Leading a Case Management Department: Today and into the Future
What Is the Difference between Leadership and Management, and Does It Matter?
Redefining Case Management
Evaluating a Case Management Department
Business Considerations for Your Case Management Department
Recruiting and Hiring Additional Staff
The Search for Case Managers, and the Retention of Valued Ones
Training and Continuing Education
Staffing
Outcomes
Positioned for Success
CHAPTER 21
Predictive Modeling and Case Stratification
What Is Predictive Modeling?
Implications for Case Management Practice
Conclusion
CHAPTER 22
New Characteristics of Today’s Healthcare Systems
Continuation of Hospital Consolidations
Continued Development of New Care Models
Growing Shortage of Physicians
CHAPTER 23
The Case Manager’s Role in the Era of Value-Based Health Care
Measuring Clinical Outcomes to Demonstrate a Provider’s
Efficient Care
Hospitals Entering New Risk Arrangements with Payers
The Role of Case Managers in Value-Based Models
Healthcare Price Transparency
CHAPTER 24
New Case Management and Healthcare Provider Approaches for Managing the High-Risk, High-Cost Patient
Identifying the Superutilizer Patient
Predictive Modeling
Population Health Management
Healthcare Informatics
Informatics and Transitions of Care for Complex, Chronically Ill Patients
Complex Care Management Models of Care
Medicaid Health Homes
PART VII FOCUS ON CURRENT CHALLENGES AND EMERGING TRENDS
CHAPTER 25
The Aging Population, Medical Advancements, and New Case Management Considerations
Our Graying Population
New Challenges
New Opportunities
Care Management
Additional Resources
CHAPTER 26
Dying in America
A Personal Story
Death Is Not an Option
Examining Your Own Feelings
Addressing the Issue of Death
DNR Orders
Pain Management
Hospice Care
Palliative Care
CMSA’S 2002 Dying in America Survey
Cultural Diversity and End-of-Life Issues
Call for Improvements in End-of-Life Care
Right-to-Die Legislation
Overprescribing of Opioids
Medical Marijuana
Conclusion
Endnote Resources
CHAPTER 27
Medication Management: A Case Management Call for Action
Medication Use among the Elderly
Problems Associated with Multiple Medication Use
In the News
Tips on Managing Polypharmacy
Medication Reconciliation
Medication Nonadherence: The Opposite Problem
Adherence Fact
The 10 Most-Prescribed Drugs
The 10 Drugs on Which We Are Spending the Most Money
Comprehensive Medication Management: Beyond Adherence and Reconciliation
What Is Comprehensive Medication Management, and Why Does It Matter?
Pharmaceutical Industry Update
When Drugs Become Deadly
Marketing Drugs Directly to Consumers
Staying Abreast of Pharmaceuticals
Conclusion
CHAPTER 28
Pain Management
Types of Pain
Assessment of Pain
The Pain Treatment Management Spectrum
Evidence-Based Practice Implications
Implications for Case Managers
Case Management Resources
CHAPTER 29
Our Nation’s Multiculturalism and Challenges to Case Managers
Changing Demographics
Acculturation and Assimilation
Implications and Opportunities for Case Managers
Language and Communication Barriers Are Problematic
The Differences Matter
Family Values
Communication Considerations
Where You Are From Does Matter
Guidance and Standards
Cultural Competency: Defining It, Achieving It
The Role of Culture in Health Care
Case Managers Make a Difference
Developing Cultural Competency
A 12-Step Program
Conclusion
CHAPTER 30
Health Literacy and Adherence Issues
Increased Need for Health Literacy
Economic Impact of Health Literacy
Literacy and Health Literacy
Day-to-Day
Considerations
Health Literacy Manifestations
The Case Manager’s Vital Role
Conclusion
Resources
CHAPTER 31
Obesity: The New Epidemic
Obesity: A Simple Definition, a Complex Problem
Metrics to Determine Obesity
Etiology
Treatment Overview
Going Forward
CHAPTER 32
Behavioral Health with Primary Care: An Integrated Model of Care
Prevalence, Cost, and Impact
Treatment Alternatives: Established and Innovative
Chronic Disease and Depression
Chronic Mental Illness and Serious Mental Illness
Partnering Successfully with Behavioral Health Professionals
Behavioral Health Disease Management Programs
Opportunities for Case Managers
Resources
CHAPTER 33
Healthcare Technology and Trends: Implications for Case Managers
Text Messaging
Mobile Health
Medical Advances and High-Cost Services
Remote Patient Monitoring
Telemedicine and Telehealth
Clinical and Business Analytics
The Macro View
And for Case Managers . . .
New Considerations Regarding EHRs
Data Breaches and Potential Ramifications for Case Managers
Ethical and Legal Issues Challenging Telehealth and Telemedicine
Open-Access Scheduling
CHAPTER 34
Transformative Healthcare Approaches for the Millennial Generation
Digital Natives
Health Behaviors of Millennials
Millennials’ Expectations of Healthcare Providers
Ramifications for Case Managers
Concierge Medicine
CHAPTER 35
The Affordable Care Act of 2010: Implications for Case Managers
Individual Mandate and Increased Coverage
Implications for Behavioral Health
Implications for Health Literacy
Implications for Patients with Disabilities
New Developments
Implications for Case Management Practice
Index
Through her many consulting and speaking engagements, Catherine is in touch with case managers from New Orleans to Chicago and Los Angeles to New York City, in practice settings from hospitals to ACOs. Continuously broadening her scope, Catherine is consistently expanding her knowledge base through perpetual reading, scanning, and the exchange of information. In her roles as contributing editor for publications such as Hospital Case Management and Case Management Advisor, and writer/contributor to Care Management and Professional Case Management, she frequently connects with editors keeping her finger on the pulse of the ever-changing world of case management. Through consulting engagements, she serves side by side with CEOs, CFOs, and medical and case management directors and case managers, helping to create and launch case management divisions, departments, and programs, reimagining, deploying, and aligning programs more completely with the CMSA Standards of Practice. She has taught case management in her “nuts and bolts,” “how-to” awardwinning course, Best in Class Case Management, as well as in customized seminars and workshops for pediatric hospitals, the Veterans Health Administration, and the Indian Health Service. She has worked with both small organizations and very large ones with complex structures and politics, always focusing on helping to accomplish their organizational goals.
Catherine’s basic knowledge of case management is as deep as it is broad. Her professional career spans multiple facets of the field. She owned and operated her own case management company for over 20 years. She headed a case management division for a Fortune 500 company. Additionally, she was a member of the group that initiated the Commission for Case Manager Certification (CCMC) credential, and ultimately was named its chair. In this pivotal role, she and her committee drafted the first Code of Ethics for CCMC. As President of the Case Management Society of America (CMSA National), she worked to establish the Ethics Statement for Case Managers. To this day, Catherine continues to contribute to those organizations. Her current business, Mullahy & Associates, has been named an official educational partner to the CCMC, for which she delivers the CCM Certification Workshop: Best in Class Case Management, helping thousands become new CCMs.
Her business is a well-respected educational resource where information and learning tools can be found on the company’s website, www.mullahyassociates.com. They include DVDs, an online learning management system, quarterly newsletters, and workbooks with all slides on flash drives to assist case managers in maximizing their potential.
No one in case management today has her unique combination of leadership
experience and the ability to connect with all individuals across the continuum of health care, from healthcare CEOs to physicians, case management supervisors, veteran and new case managers, and other professionals. It is her passion and dedication to case management and its mission, and to case managers and their commitment to their patients that sustains this deep body of her life’s work. It is also what has fueled her continuing attention to revise and expand The Case Manager’s Handbook. This Sixth Edition has again been significantly updated. Previous chapters have been enhanced with the latest data and information and six completely new chapters have been added. They include chapters on:
Pediatric Case Management
Workers’ Compensation Case Management Overview
New Characteristics of Today’s Healthcare Systems
The Case Manager’s Role in the Era of Value-Based Health Care
New Case Management and Healthcare Provider Approaches for Managing the High-Risk, High-Cost Patient
Transformative Healthcare Approaches for the Millennial Generation
As is her style, you can almost her speaking as you read the book. Catherine is the consummate storyteller. In that way, she transforms the language of difficult abstract concepts into scenes that the reader and listener can comprehend and convert into their own meaningful action. Her contagious passion for case management is embedded in every page of the book, just as it is in her seminars, workshops, and keynote presentations.
For the past 10 years, as a Vice President with Mullahy & Associates, I have had the pleasure of working side by side with Catherine. As colleagues and friends, we have worked together in case management for over 40 years. Her vision for all that case management can be is contagious and shared with every word she speaks and writes. It is amazing to watch her transform a room of silent, often skeptical nurses, social workers, physicians, and therapists into a group of enthusiastic, networking professionals filled with hope, energy, and renewed passion for case management. I believe you, too, will be both informed and inspired as you read and refer to this sixth edition of The Case Manager’s Handbook.
Best wishes for every success in case management, Jeanne Boling, MSN, RN, CCM
American cultural anthropologist Margaret Mead is believed to have said, “Never doubt that a few caring people can change the world. For, indeed, that’s all who ever have.” When compared to other groups, case managers are certainly fewer in number, but from our very earliest days, we have been making a major impact on the healthcare system, in general, but most importantly, on the patients who need our intervention most. Despite the many medical advancements we have witnessed, there remains a profound problem with our system of care wherein access to care and the right care still elude many, and where care is available, it does not automatically guarantee the best patient outcome or experience, nor the cost effectiveness of care. The provider and payer systems surrounding health care are more complex than ever, and as a blogger recently commented, “it’s easier to order a pizza than select a health plan.”
So here we all are in the era of healthcare reform and navigating our healthcare system just keeps getting more and more challenging. For case managers, these challenges come with many new responsibilities and new opportunities. It is the mission of this sixth edition of The Case Manager’s Handbook to provide case managers and others aligned with our profession the information, insights and encouragement needed to be the instruments of positive change for all patients, but especially those for whom case management was most intended: patients with comorbidities or complex health problems that require our skills and advocacy most.
From the very beginning, my goal for this book’s readers was to help each individual realize that each one of us can make a difference, and that the process of case management does not have to be as complex as some would have us believe. At its best and purest, case management is connecting an individual in need to someone who cares enough to make a difference. While we now have many sophisticated tools, software platforms, predictive modeling, and seemingly enough evidence-based practice guidelines for all the diseases known to humankind, why then are so many individuals still vulnerable and at risk within our systems? To be sure, we have to acknowledge that our role in case management has changed, and not always for the better. As more rules, regulations, guidelines and protocols consume more of our time, we wonder, what about our patients? Our professional education and experience may make it possible for us to do more and, as the size of this edition illustrates, the current environment has in fact introduced many new models of health care, treatment modalities, pharmaceutical and biological advances, technological changes, evolving legislation and regulatory matters, new financial and reimbursement issues, community resources, and so much more. What we really need to remember, however, is that patients are at the very heart of what is truly unique and special about case management. Our standards of practice and codes of conduct should be the framework that guides us and throughout the text, we
are reminded of their importance.
As predicted, the Affordable Care Act (ACA) has impacted all systems, all employers (public and private), and all providers . . . including case managers. While the need for case managers has never been greater, and the opportunities continue to expand in all practice settings, there remains a lack of formal preparation for those entering this role as well as an available resource for those seeking to improve their skills and competency. This book fulfills all of those needs and more! Additionally, with the ACA directly and indirectly resulting in an increased demand for the certification of case management professionals, it has become more important than ever that case managers continually expand their knowledge and professional credentials.
This edition of The Case Manager’s Handbook, as with the preceding editions, focuses the major portion of its text on the “nuts and bolts” of the case manager’s role and responsibilities. Because the core components, essential activities, and knowledge domains as defined by the Commission for Case Manager Certification (CCMC) are an integral part of the “nuts and bolts” of case management, this text also has been used successfully by individuals to prepare for the certification exam. As with so much in health care today, there has been an expansion of practice settings and models of care and in a direct response to these changes, readers will also find discussion of the approaches and considerations that can be applied in these newer areas and which are essential to their continuing professional development.
The emphasis on value-based health care, new technologies, the growing ranks and effects on health care of the millennials, as well as new approaches and challenges in managing high-risk, high-cost patients are just a few of the timely new topics for which new chapters were prepared in this edition. Also receiving some additional focus are those practitioners in pediatric case management, workers’ compensation, and those embarking on a role as a manager of a case management department or one as an independent case manager.
I have always held that within each case manager there is a beating heart. When each of us made the decision to become a case manager, we did so from the heart with compassion for our patients and the conviction that we could make a difference. It is my hope that new and returning readers will find not only practical information to utilize in their day-to-day work, but perhaps inspiration, knowledge, confidence, and a belief that we as case managers can, and do, make a difference . . . one patient at a time!