Download training of case managers

Accountable Care
Navigators…3
Managing
Noncompliant
Patients…6
Sample Refusal to
Consent Form…7
Case Management
Compliance Tool…8
VANTAGEPOINT
Resources…11
®
VP 2013 ISSUE 2
Case Management:
Six Principles to Enhance Care Delivery
The federal Patient Protection and Affordable Care Act, whose
“navigator,” whose main function is to aid consumers in dealing
key provisions are now taking effect, was designed to expand the
with the complexities of health insurance and healthcare reform.
number of Americans with health insurance coverage. To cope
See the sidebar on page 3 for more information.)
with the possible patient surge without compromising quality, many
providers are placing greater reliance on the principles of case
management – i.e., comprehensive care and service coordination.
An effective case management process can boost efficiency by
transforming healthcare delivery from a series of discrete episodes
into a more integrated whole.
Once limited mainly to patients requiring complex, multi-disciplinary
interventions, case management has expanded to include preventive care and patient monitoring across multiple service settings,
Better planning may potentially lower the incidence of errors and
associated professional liability claims, including
-delayed treatment
-missed referrals
-faulty diagnoses
-failure to respond properly to healthcare data
-unclear communication protocols
-failure to educate patient
such as ambulatory care centers, specialty physician practices and
Enhanced coordination of services can translate into greater patient
home care. As the case management approach is applied to a
satisfaction, reduced exposure to costly claims and a healthier
greater variety of patients and providers, it comes to encompass
bottom line. To help organizations ensure that patients receive
such new elements as wellness education, electronic information
the right services at the right time, this edition of Vantage Point ®
sharing and financial planning. At the same time, its traditional
focuses on six guiding principles of care coordination: certification
techniques – including intake assessments, patient interviews and
of case managers, early patient engagement, evaluation of health
case conferencing – are evolving within the context of a rapidly
literacy and resources, patient advocacy, adherence to evidence-
changing healthcare environment. (Note that the role of the case
based care protocols and re-engagement support.
manager is somewhat similar to but distinct from that of the
A RISK MANAGEMENT RESOURCE FOR HOSPITALS AND HEALTH SYSTEMS
1. EMPLOY CREDENTIALED CASE MANAGERS.
2. ENGAGE PATIENTS AT INTAKE, UTILIZING
As the pressure for healthcare accountability grows, so too does
A COMPREHENSIVE ASSESSMENT PROCESS.
the need for professional case managers who possess the requisite
The primary goal of case management intake is to swiftly and
education, training and skills to implement effective care coordina-
accurately gauge both immediate and foreseeable healthcare
tion. Well-honed communication, interviewing and problem-solving
needs. An array of questionnaires, checklists, computer programs
abilities are especially critical to success, enabling case managers
and other screening tools is available to assist case managers in
to obtain vital information from patients and recognize potentially
identifying patients at elevated risk of requiring chronic, costly care.
urgent situations.
For a sample medical acuity screening tool/risk stratification report
According to the Commission for Case Manager Certification
(CCMC), the demand for certified case managers is growing as
market factors impel organizations to adopt more clearly defined
from the California Quality Collaborative (CQC), visit http://www.
calquality.org/programs/clinicalcare/meteor/documents/1.1.2
CalOptima_RiskStratificationLevelsofCare.pdf.
quality standards.* Certification programs may enhance care coor-
Use of electronic resources can significantly boost case manage-
dination by helping ensure that case managers have a solid base
ment efficiency. By linking to both computerized health records
of knowledge in such key areas as
and communication portals, case management software permits
-healthcare delivery system functioning
-principles of ambulatory-based practice
-psychosocial dimensions of patient care
-rehabilitation essentials
-reimbursement systems
-clinical and financial strategic planning
To learn more about case manager certification, visit the Web sites
of the Case Management Society of America (http://www.cmsa.
org/Individual/Education/AccreditationCertification/Certification/
tabid/261/Default.aspx) and the CCMC (http://ccmcertification.
org/health-care-organizations/faqs-about-case-management).
Additionally, a wide range of professional and educational resources
is available from CCMC’s Case Management Body of Knowledge™,
at http://www.cmbodyofknowledge.com/home/public. And for
information on case management liability insurance available
through the Healthcare Providers Service Organization, visit http://
www.cmsa.org/Individual/MemberResources/InsurancePrograms/
ProfessionalLiabilityInsurance/tabid/453/Default.aspx.
* See “Growing Trend: Case Management Certification Desired [and Paid for] by More Employers,” in CCMC
IssueBrief, Volume 1:1, 2010. Available at http://ccmcertification.org/sites/default/files/downloads/2011/
3.%20Growing%20trend,%20case%20managers%20desired,%20volume%201,%20issue%201.pdf.
2
CNA VANTAGEPOINT® 2013, ISSUE 2
users to convey patient intake findings and service goals to the
treatment team within minutes of assessment. A variety of customizable electronic reporting formats is available, making it easier
to document assessment input, relay information to providers and
otherwise prevent lapses in documentation, which may be seized
upon by a plaintiff’s attorney as proof of lack of communication
and coordination.
A tool for measuring compliance with intake, care planning and
documentation requirements is included on page 8 of this publication. For additional case management intake and assessment
support, see the Resource Toolbox of the Case Management
Society of America, at http://www.cmsa.org/Individual/Resource
Toolbox/tabid/651/Default.aspx. Also, see the CQC’s Complex
Care Management Toolkit, at http://calquality.org/documents/
CQC_ComplexCareManagement_Toolkit_Final.pdf.
Accountable Care Navigators: Defining Roles and Setting Standards
The 2010 Patient Protection and Affordable Care Act (ACA)
Healthcare organizations should define in writing the scope
authorizes the certification of “insurance navigators,” who are
of permissible practice for navigators, as well as educational
trained to aid consumers in making informed decisions about
and training prerequisites. As with any new role, navigators
health insurance coverage. According to the legislation (as
initially require close supervision, especially if they lack a
recorded in the July 17, 2013 Federal Register, available
clinical background or specialized training in coordination of
at http://www.gpo.gov/fdsys/pkg/FR-2013-07-17/pdf/2013-
healthcare services.
17125.pdf), navigators are responsible for
For an overview of the various types of navigators, their history
[Helping] consumers prepare electronic and paper
in the clinical setting and a description of their primary job
applications to establish eligibility and enroll in coverage
tasks, see the Center for Health Affairs at http://www.chanet.
through the [health insurance] Marketplace and poten-
org/TheCenterForHealthAffairs/MediaCenter/NewsReleases/
tially qualify for an insurance affordability program. They
~/media/F0CEF494826441E7B379BFCD32F0646B.ashx.
also provide outreach and education to raise awareness
And for additional information, visit the following sites:
about the Marketplace, and refer consumers to health
-On patient navigator roles and training programs, see
insurance ombudsmen and consumer assistance programs
http://www.ama-assn.org/resources/doc/cms/i11-
when necessary. Navigators play a role in all types of
cms-report7.pdf.
Marketplaces, are funded through state and federal grant
programs, and must complete comprehensive training.
The ACA thus limits the navigator’s role to answering insurancerelated questions. However, some healthcare organizations
have broadened the concept, hiring registered nurses, social
workers and community care coordinators to serve as “clinical
navigators,” who guide patients through specialty and chronic
care settings. At this point, healthcare navigation may overlap
-On educational and other standards for navigators
and other assistance personnel, see https://www.federal
register.gov/articles/2013/04/05/2013-07951/
patient-protection-and-affordable-care-act-exchangefunctions-standards-for-navigators-and.
-On nurse navigator job profiles, in the form of a job
description template, see http://www.samplejobdescrip
tions.org/nurse-navigator.html.
significantly with case management, potentially creating confusion of roles.
Some healthcare organizations have broadened the navigator
concept, hiring registered nurses, social workers and community
care coordinators to serve as ‘clinical navigators’ who guide
patients through specialty and chronic care settings.
CNA VANTAGEPOINT® 2013, ISSUE 2
3
3. EVALUATE PATIENTS’ HEALTH
4. EMPHASIZE THE PATIENT ADVOCACY
LITERACY AND RESOURCES.
ASPECT OF CASE MANAGEMENT.
According to the Agency for Healthcare Research and Quality
To strengthen the importance of patient advocacy, organizations
(AHRQ), possibly as many as 90 percent of adults in the United
should include the following functions and duties in case manager
States lack the basic knowledge and skills necessary to success-
job descriptions and performance reviews:
fully manage their health and prevent disease. Various assessment
methods may be used to determine patients’ degree of
-health awareness– i.e., whether individuals possess
-Develop patients’ own skills,in order to promote
autonomy and self-care.
-Educate patients on treatment and prevention
adequate background knowledge about prevention,
measures,as well as in obtaining and completing
treatment and self-care
applications for services and entitlements.
-listening/processing skills– i.e., how clearly individuals
understand what they hear and how well they can follow
health-related directions
-
-Negotiate on patients’ behalfregarding healthcare
and social services.
-Directly arrange for necessary servicesby scheduling
navigation skills– i.e., whether individuals are capable
appointments, confirming service dates and following
of accessing needed services, handling transitions and
up on patient compliance.
finding relevant information
To access AHRQ’s Rapid Estimate of Adult Literacy in Medicine –
Short Form (REALM-SF) and a Spanish-language equivalent, visit
http://www.ahrq.gov/professionals/quality-patient-safety/qualityresources/tools/literacy/index.html.
-Provide written remindersof appointments, prescription pick-ups, medication schedules, and related
events and responsibilities.
-Map out a referral network for indicated non-medical
services, such as social, vocational and psychological
assistance.
In addition, case managers must identify resources and support
systems available to patients and families, as well as noting any
barriers to care. Once they have gained insight into patients’ lives,
they can better understand the challenges facing patients and
assist in meeting healthcare-related needs. These actions should
be prominently documented in the patient care record.
-Create a record of contactswith treatment team
members, community-based case managers and
other providers.
-Uphold patient privacy and confidentialityin contacts
with other providers and individuals, as defined by
applicable statutes, regulatory requirements and organizational protocols.
-Promote patient safety at every stage of carethrough
effective risk assessment, appropriate interventions, and
timely and thorough documentation.
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CNA VANTAGEPOINT® 2013, ISSUE 2
5. MANAGE PATIENT CONDITIONS
6. ESTABLISH A PROTOCOL
UTILIZING BEST CLINICAL PRACTICES.
FOR PATIENT RE-ENGAGEMENT.
Optimal patient care requires the integration of case management
Effective case management is an essential means of improving
with evidence-based medicine – i.e., clinical guidelines, protocols
follow-up and compliance for patients whose lives are lacking in
and pathways. These clinical decision-support tools reinforce case
structure and support. Waiting to intervene until patients present
management goals by “mapping” the sequence of care and estab-
to the next stage of the continuum of care can result in unnecessary
lishing important parameters of service, including
and costly readmissions, as well as claims alleging delayed treat-
-medical necessity criteriaand resource
utilization guidelines
-access requirementsfor elective procedures,
imaging modalities and specialty care
-referral indications,as well as specialist
selection and appointment timing
-schedule of continued stay reviewsand/or
concurrent reviews of rehabilitation, skilled
and home care services
Clinical decision-support tools also help case managers clearly
identify and document appropriate patient interventions. Guidelines make the planning task easier by illuminating certain pressing
questions, such as the following:
-What types of services are available?
-How many appointments/treatments/stays
are authorized?
-When should indicated diagnostic tests
and procedures be performed?
-To whom should the patient be referred for
consultative or specialty care?
-Where will the patient be discharged?
ment and failure to diagnose. Patients with known mental illness,
chronic conditions, adverse life circumstances and other impairments require proactive management to alter the pattern of recurrent crises and obtain continuing and appropriate medical and
non-medical attention.
A well-crafted re-engagement policy helps ensure that patients
remain within the ambit of the healthcare system as long as necessary. Hallmarks of such a policy include
-early counseling and educationof patients whose
attitudes toward self-care may hinder compliance
-written guidancefor patients on how to secure
post-discharge and after-hours assistance
-individualized patient re-engagement plans,
including 24-hour contact information for key
support persons and service providers
-documentation and communication guidelines
governing re-engagement activities
-training of case managersfor crisis and
emergency situations
-participation by case managers in patient rounds
or shift reports,and solicitation of patient input
To learn more about the benefits of evidence-based practice
Organizations should devise a written protocol to guide case
guidelines in the clinical setting, as well as potential barriers to their
managers and providers in re-engaging especially challenging
implementation, visit OpenClinical, a public-service Web site, at
patients, and in documenting these efforts in the healthcare record.
http://www.openclinical.org/clinicalpathways.html. As always,
For sample policy and documentation guidelines, see “Managing
permit providers to modify adopted guidelines based on their
Noncompliant Patients” on page 6. And for additional resources
professional judgment and clinical experience. When necessary,
on patient re-engagement, visit the Web site of the American
document any variance and associated clinical justifications in the
Hospital Association’s Hospital Re-engagement Network, at http://
patient care record.
www.hret-hen.org/index.php?option=com_phocadownload&vie
w=category&id=77&Itemid=205.
CNA VANTAGEPOINT® 2013, ISSUE 2
5
Certified case managers have an important role to play in the
ongoing effort to improve the quality, efficiency, appropriateness
Managing Noncompliant Patients
and continuity of patient care. By adhering to the core principles
When managing the medical services of difficult patients, even
of case management, healthcare organizations can enhance out-
basic expectations must be articulated and clarified, using edu-
comes, reduce exposure to allegations of mismanaged care and
cational materials, clinical reminders, and other teaching and
better adapt to the systemic changes that are reshaping the
memory aids. If a patient appears uncooperative upon intake,
healthcare landscape.
case managers should alert medical care providers to their
concerns, while documenting the potential for noncompliance
in the patient’s service plan and healthcare information record.
Also, if a patient refuses to sign the prepared service plan, the
reason for the refusal should be documented.
Both spoken and written messages to noncompliant patients
should be direct and unambiguous, but also polite and nonthreatening. When contacting such a patient, be sure to
-explain why it is vital to pursue the recommended
course of treatment, and how to arrange for necessary
treatment or otherwise rectify the situation
-send letters by certified mail, inserting a copy in the
patient’s healthcare information record
By adhering to the core principles
of case management, healthcare
organizations can enhance outcomes,
-copy assigned care providers on all written correspondence
-retain all e-mails and/or text messages sent and
received, attaching them to the patient’s healthcare
information record
-copy the member/beneficiary services department
reduce exposure to allegations of
of the patient’s health insurance plan, noting that the
mismanaged care and better adapt
another panel physician
to the systemic changes that are
reshaping the healthcare landscape.
patient is noncompliant and may require referral to
Persistent rejection of recommended treatment is a form of
noncompliance, which can imperil the patient’s health and create
potential liability for an organization and its providers. Case
managers can circumvent this risk by helping practitioners document the patient’s refusal to consent. The sample form on page
7 is designed to demonstrate that the patient has been fully
informed of the risks attendant upon forgoing a proposed test,
treatment or procedure. By signing the form, patients acknowledge that they have discussed the proposed course of care with
their provider and understand the potential consequences of
failing to comply with recommendations.
The completed refusal to consent form should become a permanent element of the patient healthcare information record. If
the patient subsequently experiences an unfavorable outcome,
this documentation serves as written evidence that the patient’s
own actions were a significant contributing factor.
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CNA VANTAGEPOINT® 2013, ISSUE 2
Sample Refusal to Consent Form
Instructions: This form should be signed by the patient or authorized party if he/she refuses any surgical procedure or medical treatment recommended by his/her physician or practitioner. If the patient or authorized party not only refuses the procedure/treatment,
but also refuses to sign this form, note this fact in the patient healthcare information record.
1. I have been advised by my physician/practitioner, (name) , that the following procedure/
treatment should be performed upon me: (name of procedure/treatment) 2. My physician/practitioner has explained to me – and I fully understand – the following points:
-the nature of the recommended procedure/treatment
-the purpose of and need for the recommended procedure/treatment
-possible alternatives to the recommended procedure/treatment, to which I similarly refuse consent
-the probable consequences of not proceeding with the recommended procedure/treatment or alternatives
3. I have read, viewed or listened to the following educational materials provided to me: (list materials, if applicable)
4. I have had the opportunity to ask questions about the recommended procedure/treatment, its purpose and probable benefits,
and any risks I have heard or thought about. (patient initials) 5. My reason for refusal is as follows: 6. I personally assume the risks and consequences of my refusal, and release the individual practitioners who have been consulted
in my case and (name of healthcare organization) , its officers, agents and employees,
from any and all liability for ill effects that may result from my refusal to consent to the performance of the proposed procedure/
treatment. This release applies to myself and my heirs, executors, administrators and personal representatives.
7. I acknowledge that I have read this document in its entirety, that I fully understand it, and that all blank spaces have been either
completed or crossed off prior to my signing.
I do not wish to proceed with the recommended procedure/treatment.
Note: This is a release of liability – read carefully before signing.
Signature of refusing patient: Date: Time: a.m./p.m.
If refusing party is other than patient:
Signature of refusing party: Signature of witness: Note: This sample form is for illustrative purposes only. As patients, clinical situations and state statutes vary, consult with an attorney prior to using this or similar forms in one’s own practice.
CNA VANTAGEPOINT® 2013, ISSUE 2
7
Case Management Compliance Tool: Reviewing Assessment,
Planning, Implementation and Re-engagement
The following checklist is designed to assist in evaluating and enhancing the various stages of the case management process, from
admission through post-discharge monitoring and follow-up.
CASE MANAGEMENT STAGE
INTAKE ASSESSMENT
1. All available medical records are reviewed by the case manager, and
the purpose of the referral is recorded.
2. Written consent for case management services is obtained from the patient,
who is informed at the same time of the right to decline such services.
3. Basic information is gathered and documented during the initial interview,
including
contact and identifying information (e.g., name,
address, telephone number, birth date)
primary language
emergency contacts
family/living situation
summary of recent healthcare services received
current medical and social service providers
health insurance status
confidentiality concerns
-
-
-
-
-
-
-
-
4. Medical needs are identified through the use of an appropriate screening tool,
taking into consideration such risk factors as
advanced age
disabilities/functional limitations
multiple diagnoses
comorbid or terminal conditions
mental illness
recent hospitalizations, rehabilitative stays
or emergency department visits
multiple medications
-
-
-
-
-
-
-
5. Social service needs are determined via an approved screening tool, noting
such risk factors as
inadequate management of activities of daily life
poor oral and nutritional health
weak family ties and/or social support network
chronic unemployment
temporary housing or homelessness
ongoing substance abuse
criminal history
lack of health insurance coverage
difficulty functioning within the social service system
due to marginal literacy and/or cultural barriers
-
-
-
-
-
-
-
-
-
6. Long-term continuity of medical care is assessed, along with patient’s
self-management skills and ability to adhere to medical regimens.
8
CNA VANTAGEPOINT® 2013, ISSUE 2
Y/N
COMMENTS
CASE MANAGEMENT STAGE
Y/N
COMMENTS
SERVICE PLANNING
1. Service plans are initiated as soon as possible after inpatient admission,
and always within 30 days of the intake period for outpatients.
2. A service plan is drafted, addressing the patient needs identified in the
intake assessment and listing
medical and social goals, which are individualized, realistic
and ranked by level of urgency
actions to be taken, plus follow-up tasks
assigned responsibilities for all parties, including the patient, care
team members, and the medical and community case managers
anticipated time frame for each activity and phase of care
patient’s and case manager’s dated signature, signifying approval
of the plan
-
-
-
-
-
3. The case management process is carefully explained, and a written list
of basic expectations is provided to the patient.
4. Appropriate consents and medical information releases are executed, as
required by applicable state and federal law.
5. Outpatients are provided with appropriate service referrals, and the patient’s
understanding of and compliance with the referral process is documented.
IMPLEMENTATION AND DOCUMENTATION
1. A comprehensive service plan is developed, which includes the
following elements:
coordination of services
confirmation of service/consultation dates
patient education regarding treatment adherence and
preventive care
skills development to facilitate patient self-management
assistance in completing necessary service applications
for outpatient care
-
-
-
-
-
2. Case managers and treatment team members confer regularly, carefully
documenting attendance, topics discussed and decisions made.
3. Patient goals and compliance levels are regularly assessed by the treatment
team,in relation to set timeframes and milestones.
4. Detailed progress notes are maintained and signed, documenting case
management activities, case conferencing and necessary follow-up tasks.
5. Service plans are assessed and updated periodically, and following any
change in patient health status or life circumstances.
6. Clinical indicators and outcomes are routinely assessed and documented,
and are reported through established quality assurance channels.
7. Outpatients are contacted regularly via whatever means of communication
works best (e.g., face-to-face discussion, telephone, e-mail or regular mail).
CNA VANTAGEPOINT® 2013, ISSUE 2
9
CASE MANAGEMENT STAGE
Y/N
COMMENTS
RE-ENGAGEMENT
1. Reassessment is performed no less than every six months after initial
assessment, in order to review the existing service plan, evaluate the
patient’s level of physical and social functioning, consider barriers to
effective treatment, and identify any additional services or consultations
that may be required.
2. Case managers are trained in crisis intervention and emergency response.
3. Emergency interventions are documented, including type of situation,
measures taken and resolution.
4. If the patient is noncompliant or uncooperative, case managers
coordinate and document a range of re-engagement strategies to
enhance retention and treatment adherence.
5. Patient counseling is initiated when necessary, and patients are reoriented
to the service plan and expectations.
6. Appropriate consents and releases are discussed and obtained, and
updated copies are filed in the healthcare record.
If the patient is noncompliant or uncooperative, case managers
coordinate and document a range of re-engagement strategies
to enhance retention and treatment adherence.
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CNA VANTAGEPOINT® 2013, ISSUE 2
RESOURCES
-American Academy of Case Management (AACM),
at http://www.aihcp.org/cs~mgmnt.htm
-American Case Management Association (ACMA),
at http://www.acmaweb.org/
-American Nurses Credentialing Center (ANCC), at http://
www.nursecredentialing.org/NursingCaseManagement
-Care Continuum Alliance (CCA),
at http://www.carecontinuumalliance.org/
-Case Management Society of America (CMSA),
at http://www.cmsa.org/
-Commission for Case Manager Certification (CCMC),
at http://ccmcertification.org/
-National Chronic Care Consortium (NCCC),
at http://www.nccconline.org/
-Utilization Review Accreditation Commission (URAC),
at https://www.urac.org/
CNA VANTAGEPOINT® 2013, ISSUE 2
11
CNA Risk Control Services
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This year-round series of courses, featuring information and
insights about important risk-related issues, is available on a
complimentary basis to our agents and policyholders. Classes
are led by experienced CNA Risk Control consultants.
CNA Risk Control Web Site
Visit our Web site (www.cna.com/riskcontrol), which includes
a monthly series of Exposure Guides on selected risk topics,
as well as the schedule and course catalog of the CNA School
of Risk Control Excellence. Also available for downloading are
our Client Use Bulletins, which cover ergonomics, industrial
hygiene, construction, medical professional liability and more.
In addition, the site has links to industry Web sites offering
news and information, online courses and training materials.
When it comes to understanding the risks faced by healthcare
providers … we can show you more.®
Editorial Board Members
Publisher
Kim A. Chisolm, JD, CCLA, CRIS
Hilary Lewis, JD, LLM
Eric Paynter, CPCU, RPLU
Mary Seisser, MSN, RN, CPHRM,
CPHQ, FASHRM
Ronald L. Stegeman
Kelly J. Taylor, RN, JD, Chair
Ellen F. Wodika, MA, MM, CPHRM
Virginia Zeigler, FCAS
Rosalie Brown, RN, BA, MHA, CPHRM
Risk Control Director
Editor
Hugh Iglarsh, MA
For more information, please call us at 888-600-4776 or visit www.cna.com.
Published by CNA. For additional information, please contact CNA at 1-888-600-4776. The information, examples and suggestions presented in this material have been developed from sources believed to be reliable,
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Copyright © 2013 CNA. All rights reserved. Published 12/13.