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Case Management - Case Management In Medicare

nursing physician clinical care services health managers

Older adults needing case management are often identified and assessed in the health care system. While chronic illness generates the greatest health care costs, medical management programs continue to focus primarily on managing acute events. Medicare beneficiaries in need of case management fall into two groups: individuals recently discharged from the hospital who have difficulty leaving home to receive needed services, and individuals receiving Medicare home health services. Medicare beneficiaries receive care through either the original fee-for-service Medicare program or through Medicare HMOs (Cassel et al.).

In the original fee-for-service Medicare program, an individual beneficiary's care is not formally coordinated among practitioners and providers involved in a case at any given time. In reality, postacute Medicare coverage and reimbursement policies serve to separate providers. There is no patient-centered case management mechanism. There is also the potential for inappropriate coordination where conflict of interest may influence care plan decisions.

From 1993 to 1995 the Health Care Financing Administration tested three different case management approaches in the original Medicare program. Although findings were mixed, case management was identified as a potentially useful service. Several factors were identified that could strengthen the case management function: full physician involvement in the care management process, highly focused goals and interventions, trained and experienced case management staff, and incentives to reduce or control Medicare costs (Foley).

The way Medicare reimburses postacute care providers will affect care management. In a cost-based reimbursement system, case managers provide assessment and coordination, and can act as a check on excessive utilization and disorganized service delivery. In a prospective payment system (Medicare risk in HMOs), case managers could facilitate beneficiary access to covered services by documenting care needs, assure appropriate communication of medical orders to providers, and make referrals for non-Medicare services.

In 1997 the Robert Wood Johnson Foundation convened an HMO Work Group on Care Management, which identified geriatric case management as an essential component for HMOs. The group, which included representatives from major health insurance companies and nationally recognized geriatricians, identified case management programs that HMOs should have in place to operate a successful Medicare risk program (Brummel-Smith). The group suggested the following components for the case management program: case selection (determining the need for intervention through information gathering), problem identification (assessing problems and potential interventions), planning (designing plans of care that reflect immediate, short-range, and ongoing needs and interventions), coordination (providing high-risk enrollees with appropriate and timely services), monitoring (periodic reassessment to determine necessary care plan modification), and evaluation (determining cost, quality of life, and quality of care outcomes). These are similar to the generic model of case management described earlier.

Whatever approach is adopted regarding case management in the original or Medicare risk programs, it will be necessary to address two basic considerations: the focus and scope of case management and the independence of case managers. These fundamental issues also apply to case management at any point on the continuum of care. While case managers may operate from a client/patient/beneficiary-centered approach, they will also be responsible for monitoring and controlling service utilization. They could also be responsible for making referrals and procuring both Medicare and non-Medicare services across the continuum of care from community resources. Medicare policy could also directly provide for and authorize access to case management itself.

Case managers' independence has two aspects, clinical and financial. There has been a continuing debate regarding the extent to which case management should be separated from the direct provision of services. A case manager who is not independent from a hospital, home health agency, nursing home, or community-based service provider may have a conflict of interest which affects his or her capacity to develop care plans that fully reflect the client's interests. Case managers face ethical dilemmas when their role creates conflict between advocating for clients and functioning as an agent for the delivery system that employs them (Browdie).

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11 months ago

Hello, I am a nurse practitioner. One of my patient's has mental problems and chronic medical problems (asthma & diabetes). He no longer has a primary care physician because she dropped him from her case load. He is in his 30's & has medicare A&B primary insurance and TennCare secondary. Can someone give me information of how I can direct this patient to get a case manager? Thank you,
Bethany

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over 1 year ago

William A. Richardson is 69 years old.
Phone number 480-494-711
On renal dialysis 3 times a week. He has been passed from one group home to another group home and is not wanted due to noncompliance.
He has social security and retirement from John Deere Company.($2,000 + a month)
He is unable to care for himself
Has no family, unable to drive, difficult to care for in a group home.