In the field of home health, the single most important individual just might be the case manager. Given the increasing pressure for all providers to assure cost-effective, high quality care, a skilled case manager can enhance quality of care and financial stability of the agency.
Quality of care: Having one individual reviewing a patient’s care is paramount to ensuring the care is:
– Appropriate for the patient’s condition. In other words, is the care provided still needed? Case managers can spot changes in the patient’s condition that may warrant modifications to the plan of care or services.
– Effective. Goals are established for all home health patients upon admission. They can range from achieving independence with performing activities of daily living and self-care to pain control and safely ambulating a certain distance. Goals are directed to particular outcomes, considering that skilled care in the home should be intermittent, and not an annuity.
– Sufficient. Because of their training, case managers are the perfect spotters for gaps in care or areas in which the patient could benefit from additional assistance to meet established goals and maintain independence.
Financial stability: The hand of CMS giveth and the hand of CMS taketh away, and lately, there is greater emphasis on the latter. Recovery audit contractors (RACs) are private companies tasked with the responsibility of identifying improper payments made on behalf of Medicare beneficiaries. They seem to be working overtime these days, scouring records for Medicare dollars that can be recouped. It doesn’t hurt that RACs are motivated by a contingency fee for successful recoveries. However, a strong case manager, wearing a RAC-like hat, can scrutinize the documented (or lack of documented) patient care and assess whether the case meets medical necessity. He or she can also coach clinical staff on proper documentation to support appropriate care. It’s no secret that documentation is usually the lynch-pin to any recovery case.
We always say that the key to a deficiency-free survey is a robust quality assurance program and the case manager can be instrumental to that effort. For some agencies, QA is a rote exercise. Checking a box on a form is not a true embrace of the purpose of performance improvement, which is to be on the look-out for instances or patterns that could spell trouble and to employ a systematic, objective process for identifying root causes and generating solutions. When a home health case manager reviews a case, he or she is uniquely positioned to identify potential issues that merit further quality study.
Case management is an integral part of a citation-free and a RAC recovery-free operation. Further, proper case management benefits the patient’s recovery and supports achievement of goals for a healthier daily life. As the old saying goes, ‘You can spend a little now or a lot later.’ Training, education, emphasis and support of the case management personnel and process are time and money well spent.