| Contributors |
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xi | |
| Preface |
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xiii | |
| PART I---THE FUNDAMENTALS |
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1 | (38) |
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Organizational Structure of Case Management Programs |
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3 | (26) |
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4 | (1) |
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5 | (1) |
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Roles and Responsibilities |
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6 | (5) |
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11 | (5) |
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Organizational Structure and Reporting |
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16 | (5) |
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21 | (8) |
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29 | (10) |
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Case Manager Roles and Responsibilities |
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30 | (1) |
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30 | (2) |
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To Grandfather or Not To Grandfather |
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32 | (3) |
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Staff Qualifications and Credentials |
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35 | (2) |
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37 | (2) |
| PART II---GUIDE TO UTILIZATION MANAGEMENT |
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39 | (96) |
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What Every Case Manager Should Know about Managed Care |
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41 | (10) |
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41 | (2) |
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Using the Rules To Facilitate Patient Care |
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43 | (3) |
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Discharge Planning upon Admission |
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46 | (1) |
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Health Care Team Conferences |
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47 | (1) |
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Ensuring That Coverage Requirements Are Met |
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47 | (1) |
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Inpatient Decision Points |
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47 | (1) |
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48 | (1) |
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What Managed Care Has Provided for Us |
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48 | (3) |
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Understanding Utilization Management |
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51 | (12) |
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Utilization Review versus UM |
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52 | (1) |
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The Role of Standards and Clinical Criteria in UM |
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52 | (4) |
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Infrastructure Elements To Support UM Activities |
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56 | (1) |
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The UM Process in the Inpatient Setting |
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57 | (3) |
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Collaboration with the Physician |
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60 | (1) |
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The Physician Advisor Role |
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61 | (1) |
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Integration of UM and Care Facilitation |
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62 | (1) |
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Understanding Chart Review |
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63 | (8) |
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64 | (1) |
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Concurrent, Continued Stay Review |
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65 | (3) |
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68 | (3) |
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Denial Management and Related Care Coordination |
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71 | (10) |
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72 | (1) |
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Components of an Effective Denial Management Protocol |
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73 | (6) |
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Denial Management and the Contracting Process |
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79 | (1) |
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The Role of the Case Manager in the Denial Management Process |
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79 | (2) |
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Physician Partnering and the Case Manager's Role in Conflict Mediation |
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81 | (14) |
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Building Skills To Manage Conflict |
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82 | (2) |
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Identifying Each Stakeholder's High-Priority Interests |
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84 | (2) |
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Assessing and Improving Conflict Management Skills |
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86 | (1) |
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Establishing Effective Partnerships between Physicians and Case Managers |
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87 | (5) |
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The Case Manager as a Clinical Expert and Staff Development Resource |
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92 | (1) |
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Meeting the Collaborative Practice Challenge |
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93 | (2) |
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Patient Rights and Effective Communication Techniques |
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95 | (14) |
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The Role of the Case Manager in Addressing Patient Rights |
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95 | (8) |
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Legal Implications Associated with Care Facilitation and Discharge Planning |
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103 | (2) |
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The Impact of Specific Communication Styles on Managing and Facilitating Care |
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105 | (4) |
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Regulator Impact on Daily Work Flow |
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109 | (26) |
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110 | (5) |
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Eligibility, Enrollment, and Supplemental Security Income (SSI) Information |
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115 | (4) |
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Differentiation of Traditional versus Managed Medicare/Medicaid |
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119 | (1) |
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120 | (2) |
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Hospital-Issued Notices of Noncoverage (HINN) |
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122 | (1) |
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Denial and Appeal Process |
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123 | (1) |
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123 | (2) |
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125 | (2) |
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127 | (1) |
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Implications of the BBA of 1997 |
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128 | (7) |
| PART III---DOCUMENTATION AND MEASUREMENT |
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135 | (44) |
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The Role of the Case Manager in Hospital Preparation for Joint Commission Accreditation |
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137 | (24) |
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138 | (2) |
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140 | (1) |
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140 | (2) |
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Joint Commission Standards Related to Case Management |
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142 | (19) |
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The Case Manager as a Facilitator of Accurate Medical Record Documentation |
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161 | (18) |
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The Medical Record as a Medical Document |
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162 | (1) |
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The Medical Record as a Confidential Legal Document |
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162 | (1) |
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Medical Record Ownership and Responsibility |
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162 | (1) |
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162 | (1) |
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162 | (7) |
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The Business of Achieving Accurate, Through, Consistent Documentation |
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169 | (4) |
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Guidelines for the Selection of a Principal Diagnosis |
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173 | (6) |
| PART IV---TRANSITION FROM DISCHARGE PLANNING TO COMMUNITY-BASED CASE MANAGEMENT |
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179 | (72) |
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Transition Planning (Discharge Planning) |
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181 | (10) |
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Driving Forces That Have Influenced Transition Planning |
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182 | (1) |
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What Is Transition Planning? |
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182 | (1) |
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Purpose, Goals, and Objectives of the Transition Plan |
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183 | (1) |
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The Transition Planning Process |
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183 | (1) |
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Formulating the Transition Plan |
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184 | (4) |
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Roles of the Case Management Team |
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188 | (2) |
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190 | (1) |
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191 | (10) |
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Postacute Admission Criteria |
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193 | (6) |
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199 | (2) |
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201 | (16) |
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202 | (1) |
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202 | (1) |
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Indicators and Predictors of Home Care Demand |
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203 | (4) |
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Home Care Services and Disciplines |
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207 | (1) |
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208 | (2) |
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Regulations Guiding Home Care |
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210 | (1) |
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Financing Home Care Services |
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211 | (3) |
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Recent Legislation and Regulatory Issues Affecting Home Care |
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214 | (1) |
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Measuring Quality in Home Care Services |
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215 | (1) |
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Examples of Advanced Clinical Practices in Home Care |
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215 | (2) |
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Hospice and End-of-Life Care |
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217 | (14) |
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Medical Management and End-of-Life Care |
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217 | (3) |
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The Basics of Hospice Care |
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220 | (1) |
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Financing and Reimbursement |
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221 | (1) |
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Size of the U.S. Hospice Industry |
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222 | (1) |
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223 | (2) |
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225 | (1) |
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Hospice Cost and Staffing |
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226 | (1) |
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227 | (1) |
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Future Integration and Affiliation Strategies |
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228 | (3) |
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Community-Based Case Management |
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231 | (12) |
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Incentives To Establish Community Case Management |
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232 | (1) |
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232 | (3) |
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Components of Community Case Management |
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235 | (3) |
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Providing Case Management |
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238 | (2) |
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Primary Disease and Demand Management Initiatives |
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240 | (3) |
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Communications between the Hospital-Based Case Manager and the Payer |
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243 | (8) |
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What Information To Communicate |
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244 | (4) |
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248 | (1) |
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249 | (2) |
| PART V---INFORMATION TECHNOLOGY SUPPORT FOR CASE MANAGERS |
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251 | (20) |
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The Case Manager's Guide to Hospital Cost Accounting Systems |
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253 | (12) |
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Cost Accounting Concepts and What a Case Manager Should Know about Them |
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254 | (4) |
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A Case Manager's Use of a Hospital's Cost Accounting System |
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258 | (3) |
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Words of Advice in Using Cost Accounting Information |
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261 | (4) |
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Decision Support for Case Managers |
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265 | (6) |
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265 | (1) |
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266 | (1) |
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Types of Decision Support Systems |
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267 | (3) |
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270 | (1) |
| PART VI---MODELS FROM MEDICAL CENTERS REDESIGNING CASE MANAGEMENT |
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271 | (26) |
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273 | (10) |
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Evolution of Rapid Design |
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273 | (1) |
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The Accelerated Solutions Methodology |
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274 | (1) |
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Indications for Use in Care Management |
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275 | (1) |
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Case Management Infrastructure Case Study |
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275 | (8) |
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Improving the Care of Complex Populations: A Case Study in Clinical Redesign of Patients with Acute Myocardial Infarction |
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283 | (4) |
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283 | (1) |
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Identification of Areas Needing Improvement |
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283 | (1) |
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Data Collection and Analysis |
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284 | (1) |
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284 | (1) |
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285 | (1) |
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286 | (1) |
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286 | (1) |
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Improving the Care of Complex Populations: A Case Study in Clinical Redesign on Extremely Immature Neonates |
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287 | (6) |
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287 | (1) |
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Identification of Areas Needing Improvement |
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288 | (1) |
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Data Collection and Analysis |
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288 | (1) |
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289 | (1) |
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289 | (1) |
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289 | (1) |
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289 | (4) |
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Improving the Care of Complex Populations: A Case Study in Clinical Redesign on a Trauma Service |
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293 | (4) |
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293 | (1) |
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Identification of Areas Needing Improvement |
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294 | (1) |
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Data Collection and Analysis |
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294 | (1) |
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295 | (1) |
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295 | (1) |
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295 | (1) |
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296 | (1) |
| Glossary |
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297 | (8) |
| Sources |
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305 | (2) |
| Index |
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307 | |
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