Managed Care & Case Management

Medical SurgicalCritical Thinking

ForCollaborative Care

Learning Objectives

• Explain the primary purpose of Managed Health Care• Contrast the fee-for-service and capitated reimbursement

systems for health care• Compare the Health Maintenance Organization with the

Preferred Provider Organization• Delineate the overall goals of Case Management• Explain the role of Case Management based on National

Standards• Identify at least three certifications for Case Managers• Clarify the differences and similarities between case

management and disease management

Managed Health Care

• A system that attempt to control cost by using select group of providers who have agreed to a set payment before delivering care

• Client care is outcome driven & managed by a utilization and or case management process

• Factors driving cost and quality• Aging• Purchaser pressure to contain costs• Physician & consumer resistance to “tight” management

and referral control• Renewed emphasis on evidence-based practice

Managed Care

• Fee-for-service – hospital, physicians, and other health care providers were paid by health insurance companies on the basis of what the providers billed for their services

• MCOs standardize and control cost• Health care providers receive a uniform

amount of money for each client—capitated reimbursement

• MCO – HMO, PPO

Case Management• The assumption the client need assistance using the health care

system and its resources effectively• Goals: By ANA• To provide quality health care along a continuum of care• To decrease fragmentation (and duplication) of care across health

care settings• To enhance the client’s quality of life• To increase cost containment (thru appropriate use of resources)• BY CMSA: To enhance an individual’s safety, productivity,

satisfaction & quality of life• To assure that appropriate services are generated in a timely and

cost-effective manner

Process of Case Management

• Needs Assessment– Assess/collect data– Conducts case screening– Identifies client’s support systems and care providers– Review history and determines current health care needs obtains approvals for contracts

• Plan Development– Identifies services and funding options– Reviews plan for consensus– Advocates for client as needed– Develop plan of care as indicated

• Implementation & Coordination– Communicates regularly w/client and support system– Coordinates treatment plan– Promotes coordinated and efficient care– Identifies needs for additional services

• Outcomes Monitoring and evaluation– Assess benefit value to cost & value to quality of life– Review plan for continuity of care– Evaluates client satisfaction and compliance w/treatment plan

• Documentation– Records services and outcomes– Submits report & other documentation as needed

Standards for Case Management Practice

• The standards describe responsibilities, delineate expectations, & define accountabilities:

• Roles includes: assessment, planning, facilitation, and advocacy

• Three certifications:• CCM – certified case manager• CDMS – certified disability management

specialist • A-CCC – advanced certification in continuity of

care

Differentiations

• Disease management is across the continuum, system-based approach to care for populations of clients w/ chronic, complex illnesses; it uses case management as the process for providing care.