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 best then is mediocre now. What is now required is a new philosophy encouraging a forward-thinking culture that reacts to change quickly, and at times, proactively leads the change. What we need now are “leading practices.”

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. This model creates three distinct parts: utilization review, care coordination and discharge planning. Each part is performed by three different individuals. Unfortunately, this practice has created the risk of communication silos as well as work flow that 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 the past eight weeks with very early evidence of measurable improvements. In Facility A, the outpatient observation rate is down from 24 percent to 18 percent and holding, while insurance denial rates improve. 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 are improved in the areas of nursing communication, up 7.5 percent; doctor communication -- up 28 percent; communication about medicines, up 15.5 percent; and transition of care up 6.1 percent. “Overall hospital rating” score is up by 24.7 percent and hospital acquired conditions (HACs) are at zero. This is significant for this unit as they have had a history of 3-6 HACs per quarter for some time. These early outcomes are encouraging.

To further modernize the process 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 that literally scans and reviews every patient’s EHR in near real time versus the accepted “best practice” of the manual application of a commercial screening tool that may be at odds with a payer’s 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 and 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 would allow a quick drill down to the patient most at risk with 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