By Alan Gilbert
There can be no question that recent health insurance and the health information technology reforms out of Washington have prompted stakeholders throughout the healthcare industry to seek solutions with the potential to increase access to quality care while better managing costs.
This realization has motivated organizations wanting to achieve genuinely coordinated care and formal recognition by CMS as an accountable care organization (ACO) to integrate the administrative, financial, and clinical components involved in the care of patients. Specifically, this entails combining the case management and utilization management data with the clinical repository. This aggregation of data enables the development of chronic and acute disease and wellness programs designed to influence individual behavior and positively impact overall health.
Case and utilization software empowers case managers by granting secure access to a patient’s longitudinal clinical history in real time. At any point in the care plan development and management workflow, a case manager can access their patients’ most recent laboratory results, medication prescriptions and refills, radiology images, diagnosis codes, Emergency Department admissions, consultation notes, discharge summaries, etc. Equipped with this level of detail, case managers can better coordinate with providers so patients and their caregivers have timely access to the most appropriate care available.
To achieve this level of functionality, case management solutions should include features such as:
- Case activity captured in a single case record
- Online, user-defined assessments
- Link to track standard treatment guidelines
- User-defined tables to customize a unique list of problems, goals, barriers, interventions, status codes and acuity levels
- Outcomes for each case
- Ability to auto-assign a patient to case management when authorization referral requests are received, as well as to manually open a case from referrals outside the automated system (e.g., family member, social worker, etc.)
- Audit logging of important data changes
- Online work lists, easy search filters and helpful reminders that prompt case managers to ensure timely follow-up on active cases
The latest utilization management (UM) solutions rely upon automation to help risk- and non- risk-bearing organizations to support cost-efficient delivery of medical services. Patient eligibility, benefits and patient clinical data determine acuity levels, which allows advanced rules engines to auto-adjudicate authorizations and referrals that have been entered online. Authorizations and referrals that are pended – because of outlier characteristics, for example, or the complexity of the case – are routed to a work queue for review and management. The UM software should be able to leverage clinical data to automatically route or refer the patient to case management.
Organizations seeking this functionality from utilization management software should determine whether solutions under consideration include:
- Eligibility inquiry capability
- Provider inquiry capability
- Authorization guidelines and rules defined and maintained
- Care guidelines
- Immediate authorization status response functionality
- User-defined protocol rules that result in approving, pending, and/or denying authorizations
- Configurable authorization work-list queue functionality
- Routing of pended authorizations to another party for review
- Concurrent review notes and “level of care” information
- Secure internal messaging
The new environment clearly places the patient at the center of all healthcare processes, with members of the extended care team considering options and making decisions in concert. Technology must be implemented to help these care teams monitor, track, treat and report on every patient at every point of service. Case and utilization management, combined with access to discrete clinical data, should be able to deliver tangible results such as:
- Reduced readmissions,
- Lower cost of care for patients through chronic disease management and preventive care
- Elimination of duplicate tests
- Greater efficiency with auto-approval of referrals and authorizations
As Bob Dylan famously sang, “The times they are a-changin’.” But the emergence of new care models, supported by flexible and scalable care coordination technologies, will help healthcare organizations navigate the new landscape and reap the projected benefits more quickly.
Alan Gilbert is the vice president of Business Development for AxSys Technology, Ltd., which specializes in the development and implementation of clinical solutions to improve and coordinate the delivery of healthcare.