Delivery Models and Reimbursement: Can Evidence Override History

Thomas, Patricia

PROBLEM

The cry for healthcare reform resounds in all sectors of the United States economy. Although most policy makers agree on universal coverage, there is not agreement on how to finance the system. Case management has been identified as a mechanism to manage length of stay (LOS) and authorization for payment. In spite of this, organizations struggle with inconsistent and varied criteria to evaluate effectiveness of case management delivery models.

LITERATURE REVIEW

The full immersion model of care management was built from concepts in the case management literature related to role functions of discharge planning, utilization review, and care coordination or facilitation (Huber, 2006, Marquis, & Huston, 2003, Powell, 2000). These functions require collaborative relationships between health care providers and the identified payer for payment of services rendered.

METHODS

This retrospective, causal comparative study examined the traditional case management delivery model and a newly developed (modified) case management model to identify if a relationship existed between LOS and payment denials grounded in case management role functions.

PRACTICE CHANGE

This study involved modification of the case management role functions and staffing patterns. Current case management role functions were examined and a new model of care delivery was established to address perceived gaps in service. The changes included expected communication patterns, documentation processes, and coordination of the plan of care. The modified case management delivery model was implemented on adult medical, surgical, and cardiology units across general, intermediate, and intensive levels of care.

EVALUATION

LOS data were analyzed for each nursing unit that implemented the modified case management model and compared to the same population of patients in the previous year. Payor data was analyzed for LOS and payment denials.

RESULTS

A statistically significant reduction in LOS occurred when the caseload staffing patterns and role expectations for the modified model of case management were implemented. LOS did not have a statistically significant impact on denials, appeals, or payment status. LOS for appealed, denied, or partially denied cases was actually higher than those paid in full. The payer source did not have a statistically significant influence on LOS and managed care plans did not have a statistically lower LOS compared to traditional contracted plans.