Hospital Case Management Module

Hospital case management is a process for evaluating medical care efficiency. The case manager identifies appropriate levels of care and considers alternative therapies and resource usage. To measure improvement in medical care efficiency, the practitioner presents care providers with specific opportunities to improve and monitors their progress over time.

The Hospital Case Management module provides a suite of tools for tracking and authorizing services across the continuum. The module includes entry forms for certification, authorization, concurrent review, avoidable days, and discharge planning. You can track avoidable days and denial detail by department, provider, or payer attribution, and quickly review the appeal history, including days and dollars recovered. Discharge planning is easy; case reviewers can quickly scan support service history for a patient or health plan member.

A real-time interface with your existing information system populates the Hospital Case Management module with patient data and/or membership demographics, encounters, coded diagnoses, procedures, and financial data. The entire hospital case management process is tied to individualized worklists for automatic notification of reviews and follow-up.

The Hospital Case Management module includes tools for online documentation, physician referral, electronic mail, and online faxing so that you can transform your entire review process to a paperless one.

Features and Benefits

Implement a completely paperless process
Promote real-time collection of patient data from existing information systems
Review a daily worklist with patients assigned by facility, location, room number, physician, or payer
Control the creation and status (pending and completion) of initial reviews, schedule reviews in the future, and readily access a history of reviews
Access user-defined, InterQual® criteria sets, MCAP criteria, or Milliman® healthcare guidelines for each review (separate licenses required)
Automate the referral process, including physician referrals
Referrals to physician advisors include the reason and physician follow-up comments
Define Comment templates to facilitate the organization of review data.
Certify, deny, and record acute, non-acute, denied, avoidable, and grace days within the patient's stay
Initiate discharge planning and placement within the MIDAS+ system, or link to a Webbased patient placement engine such as eDischarge™
Assign a cause, physician, and/or department attribution to avoidable or denied days, and manage a denial's appeal process
Reduce denied and avoidable days, lengths of stay (LOS), and readmissions
Define letters using MIDAS+ data fields and send them to patients, physicians, or payers
Generate productivity, denial, avoidable day, physician advisor, and discharge planning agency referral reports
Fax or e-mail review worksheets to payers

"I think what speaks loudest is the set of initial outcomes generated by the Senior Outreach program at Mercy Health Partners Northern Region. Briefly they are: Inpatient admissions decreased 56%; ED visits decreased 75%; of 77 clients served, 74% had no admissions or ED visits in 2002; 80% of clients reported improved quality of life; cost savings in excess of $75,000 from reduced hospital utilization."

David Yost
B.S.N., R.N., Manager, Decision Support,
St. Rita’s Medical Center,
Lima, OH