The “Right Care” Case Management Model

As healthcare reforms, some “best practices” are simply failing to manage the seemingly constant change in our industry.

What was once seen as the best is simply mediocre now. What is now required is a new philosophy. It must encourage a forward-thinking culture that reacts to change quickly, and at times, proactively leads the change.

It’s vital to move beyond best practices. The world of healthcare needs “leading practices,” and especially for case and care management models.

Leading Practices in the Case Management Model of Care

In establishing a leading practice in Case Management, we performed an unfiltered assessment of the triad model, which is the current care delivery Case Management model.

The triad case management model includes three distinct parts:

• Utilization review
• Care coordination
• Discharge planning

Each part of the workflow is performed by three different individuals. Unfortunately, this practice has created the risk of communication silos. This can negatively impact patient care and throughput while creating a multitude of other barriers.

Using Einstein’s idea that problems cannot be solved “with the same thinking that created them,” we made a decision to turn the triad model on its side. As a result, “Right Care” was envisioned.

The “Right Care” Case Management model is an interdisciplinary hourglass model designed to manage the flow of resources needed by a patient proactively versus “chasing” to review and validate the use of resources after they’ve been consumed. It’s an innovative, non-traditional process that moves away from the triad cylindrical structure that leads to the risk of silos.

The pilot for Right Care has been implemented in two hospitals over eight weeks with very early evidence of measurable improvements.

Facility A: Right Care Case Management Model Results

In Facility A, the outpatient observation rate is down from 24 percent to 18 percent and holding. Additionally, insurance denial rates have improved.

Facility B: Right Care Case Management Model Results

In Facility B, on a single medical unit, the outpatient observation rates are holding at 10 percent, and the inpatient length of stay is down, saving 100 excess days. The patient satisfaction scores for the Facility B medicine unit improved in the areas of:

• Nursing communication, up 7.5 percent
• Doctor communication, up 28 percent;
• Communication about medicines, up 15.5 percent
• Transition of care, up 6.1 percent

Additionally, "overall hospital rating” score rose by 24.7 percent and hospital-acquired conditions (HACs) are at zero. This is significant for this unit. It had a history of 3-6 HACs per quarter for some time. These early outcomes are encouraging.

Right Care Cse Management Model: Final Thoughts

To further modernize the evidence-based case management model we’ve identified the need to use technology to manage the utilization review.

UR is an important beast that, left unattended, will gorge itself on precious productivity while potentially leaving behind poor outcomes and financial impacts. Our solution is using an evidence-based, automated utilization review platform.

Our solution, called CORTEX®, scans and reviews every patient’s EHR in near real-time. It provides clinicians and administrators valuable insight, analysis, and forecasting. Patients can receive more targeted and focused care. At the same time, facilities can benefit from more accurate patient statuses and improved payer communications.

That stands in stark contrast to the accepted “best practice” of the manual application of a commercial screening tool. And that tool may be at odds with a payer’s own commercial screening tool.

To keep up with health care reform, Case Management must leave behind the human-error prone best practices of the current legacy models. It’s crucial to develop leading practice models powered by technology, as other areas of healthcare have been doing for years.

The use of technology to create automated risk triggers for discharge planning, readmissions, clinical care and utilization review is central to the effectiveness of these new types of case management models. The right technology can positively influence case management nursing models and many others.

They allow a quick drill down to the patients most at risk. Additionally, they offer a potential side benefit of improved patient experiences, as noted in some of our early Right Care trial findings.

Through forward-thinking practices and technological tools, Case Management can write its own evidence-based practice for the 21st century.

Rikki Moye, RN VP of Case Management