case management; chronic care management

Introduction

An approach to patient care attempting to improve the technical quality of services that may decrease overall utilization of health care services.

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• Goals:
  • to provide quality care at least cost
  • to reduce waste, redundancy, length of stay, cost
  • to coordinated care pathways, practice guidelines, assessment & care planning, MDS/RAPs/RUGs, outcome measures
  • to ensure integration with other levels in the healthcare system to produce seamless movement of the patient through the system
  • implementation may increase revenue for the work being done

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• Types:
  • internal: employee(s) of facility
    • assess potential admissions
    • facilitates care on the unit
    • interfaces with external managers
  • external
    • case managers associated with outside organizations contracting with the facility

Notes

• nursing-led case management (including medication adjustment) may lead to modest improvements in surrogate outcomes for diabetes mellitus (HgbA1c), chronic hypertension & hyperlipidemia (LDL cholesterol)
• Center for Medicare & Medicaid Services (CMS) provides reimbursement
  • there are billing codes that can be used by primary care providers in outpatient, assisted living, home, & nursing home settings for time communicating with patients outside the office
  • billing can be done by physicians or nonphysician practitioners & their clinical staff
  • patients qualify for CCM if they have 2 or more chronic conditions expected to last at least 1 year or result in risk of death, decompensation or functional decline
  • the billing organization must have
    • electronic medical record (EMR)
    • a team that provides
      • continuity of care
      • care planning/management
      • transitional care management
      • coordination of services, 24/7 access
      • availability for enhanced communication (such as via patient portal in an EMR)

More general terms

• clinical process

More specific terms

• chronic care management program
• Collaborative care model
• community-acquired pneumonia assessment
• COPD assessed
• management of inflammatory bowel disease
• management of major depression

Additional terms

• Care Management Plus