Risk Management Issues: Telephonic Case Management - Essay Example

? Risk Management issues: Telephonic Case Management Risk Management Issues: Telephonic Case Management Introduction Telephonic casemanagement is a sensitive issue which must be highly considered in every hospital setting. It is a proactive strategy which focuses on early intervention which is applied to manage any medical cases that may delay prompt and healthy return to work. Remarkably, it is noted as a short period cost containment service whose effectiveness depends on the speed at which it is implemented in the instance of an illness or injury (Fero et al., 2010). Moreover, it is aimed at attaining high quality clinical care and ensuring that closure of a case is attained in the shortest time possible. Significantly, telephonic case management is valuable in the provision of essential information on the severity of a given injury, and the complicated issues that may emerge. It also gives a detailed overview on the available opportunities for an early resumption of work. Broadly, it is concerned with the assessment of the injured worker’s medical needs, review, monitoring and evaluation of the available treatment choices, and the facilitation and harmonization of an effective communication among the employer, employees, and claims personnel to assist in a well-timed return to work (Fero et al., 2010). This service greatly impacts on the employers base lines through a reduction on the number of days the employees are off work due to the illness. In the provision of the telephonic case management services a highly qualified staff is required to bridge the gap between the employer and the injured employees. In the hospital facility the telephonic managers bring together the concerns of the hospital administration and any injured hospital staff for a quick treatment and cost settlements to achieve a timely return to work plan. Steps Taken to Address the Risk Management Issue Several steps have been discussed to address the issue of risk management in the hospitals. Remarkably, utilization management has greatly been considered in the push to attain a greater impact in the process of predictive modeling and data analysis. This step incorporates the effective evaluation of medical need, suitability and efficacy of the application of health care, processes and the facilities envisioned in the provision of an appropriate health benefits plan. Notable under this step is the hiring of highly qualified and experienced nurses who have been in the clinical practice for at least three years in the highly demanding and sensitive units in the hospitals such as the neurology, emergency room, radiology and the orthopedic units. There is also the employment of several board certified physicians who are important in the monitoring and evaluation of all the aspects of medical care while carrying out concurrent and retrospective reviews (Reilly et al., 2011). Case management is another step which has been employment by the hospital in its endeavor to solve the risk management issues. This has been provided to enhance a collaborative assessment process, the planning, facilitation of dialogue and timely settlement, the promotion of alternatives and services to meet a client’s health requirements via communication and existing resources to offer better quality, cost effective results. In view of these, a state of the art proprietary soft ware necessary for effective negotiation between the hospital managers and the ill workers has been installed to achieve a timely and cost effective communication. Through the electronic data interfaces (EDI), the hospital administration and the injured employees are able to download the case process, evaluate them and post their responses in time (Reilly et al., 2011). This facilitates a quick conclusion of the claims since the concerned parties can communicate immediately. Another notable step has been employed in the disease management process. Remarkably, disease management is the system of synchronized wellbeing interventions and dialogues for the hospital staff with conditions under which the sick person’s self-care efforts are crucial. This management process promotes the relationship between the physician or the medical practitioner and the patient under consideration. It allows for the care planning, emphasis on prevention of emanating exacerbations and impediments, empowerment approaches for the patient and the ongoing evaluation of the humanistic, clinical and economic results aimed at enhancing the ultimate patient health (Powell et al., 2007). The disease management aspects consist of: evidence-based procedures, identification of the hospital population under consideration, applied practice plans and models that include the physicians and the support staff. Moreover, it includes the measurement on the applied processes and results, monitoring and evaluation of the models, the feedback loop consisting of the physician, the patients and the hospital health plan and ultimately the patient self-assessment knowledge. Notably, this disease management step is aimed at the management of various chronic diseases such as the cardiac arrest, asthma, pulmonary diseases and the diabetes. Highly trained nursing officers are engaged to enhance education interaction between the telephonic respondents and the patients (Powell et al., 2007). Educational materials both print and over the Internet are sent to the patients constantly reminding them to follow the medication prescriptions. Furthermore, in the push to address the risk management issues, the hospital has discussed the establishment of a health call center within the hospital facility. This will be necessary to provide health related information and triage to the patients when contacted through the internet, the telephone or any appropriate electronic media (Powell et al., 2007). With the provision of the health information telephonically, patients receive timely and cost effective services. Remarkably, the in-bound calls to the health call centers are normally received by a non-medical staff that is tasked with the collection of the demographic data on the patient. Technology has allowed the transfer of this recorded information to the RN who in-turn utilizes algorithms to facilitate the rendered medical advice. In solving the risk management issue, the hospital has engaged in a step by step plan to engage an independent review to establish if a health care plan is medically obligatory and appropriate to cover its patients and workers. This review has been necessitated by the increasing concerns of disgruntled workers and patient claims. It is independent of the concerned parties and hence will give the hospital management a detailed overview of the problem at hand. This review involves the engagement of a quality improvement organization which has been in operation for over thirty years in the Medicare and Medicaid services (Powell et al., 2007). Approach in Setting the Solution Path With the increasing issues of highly demanding clinical claims, the management found it wise to conduct a study on the approaches necessary to avert the problem. A research was carried out in consideration of all the available case management concepts which include: case management process, resources, outcomes, administration and leadership, regulations related to the case management, the communication and medical skills and the techniques necessary for the case managers as recommended by Carroll (2001). Moreover, to identify a solution, my agency analyzed the case management concepts in terms of the good principles of practice such as the quality, risk management and the related legal and ethical issues as well as the certification of service providers. Furthermore, healthcare management, reimbursement and delivery were also considered. These give a detailed overview of the expected investment returns while balancing the quality of the health care. In consideration of the above criteria, it is noted that timely and prompt back to work formula, appropriate compensation are necessary to reduce the liabilities associated with the hospitals. In view of this, a highly qualified telephonic case manager was required to mediate between the hospital administration, the injured workers and the disgruntled patients (Carroll, 2001). This ensured a better working environment for the hospital staff and made it possible to achieve patient satisfaction in respect of the on provision of quality medical services. Many hospitals have greatly applied the use of utilization management, case management and the disease management methods in a bid to solve emanating risk management issues. There has been an increased involvement of telephonic case managers to effectively and appropriately monitor and evaluate the risk related claims to safeguard the hospitals from incurring losses (Carroll, 2001). Moreover, the employment of the telephonic case managers has been necessitated by the growing concern of an amicable settlement of claims between the patients, injured hospital workers and the hospital administrations. The management of better health benefits plan requires an intensive research and responsible persons who will carry out an on going research on the changing trends of health schemes. Coventry Workers’ Comp Services has applied telephonic case management to assure proper treatment and the establishment of effective return-to-work plans. The organization applies powerful proprietary software which helps in managing the various cases that the organization handles. The system has enabled effective negotiations between injured workers, employers and service providers and the quick resolution of issues (Coventrywcs 2012). The Crawford Company is yet another organization that applies telephonic case management in helping people meet their health needs (Crawford Company 2012). The organization assesses injured workers’ medical needs and evaluates the treatment options. The company then coordinates communication and actions amongst the various stakeholders. With several health experts forming part of its workforce, the organization boasts of having a successful closure rate of 97%. Gold Choice which is a managed care organization that cares for the mentally impaired and those diagnosed with problems related to drug abuse utilizes telephonic managed care to link clients with primary care providers (Kahn, Aiello, Berdine, & Fox (2009). Once the parties are linked, the clients continue to receive services through telephonic case management. The organization notes that the service is effective in linking mentally retarded persons with primary care providers. Like organizations such as the Crawford Company and Coventry Workers’ Comp Services our hospital has seen high success since it started reviewing its performance under the direction of an independent reviewer. The hospital noted that one of its failures was in respect of turnaround time as cases were being handled sluggishly. Yet again, the reliance on a third party to monitor and evaluate the quality of services offered by the hospital in respect of case management has proved quite effective as patients and workers have recorded better satisfaction rates. Conclusion and Recommendation In the current world, health care has become dramatically complicated field with increasing changes in the science, technology and regulation of health matters. In view of this, the medical claims, settlements and medical expenses associated with the health matters have significantly escalated. It is every hospital’s administrative concern to cut on these liabilities and ensure adequately satisfied clientele. This concern has forced the hospitals to engage professionals in the management of these emerging claims with the involvement of telephonic case managers. Risk management is a very important aspect in the management of the hospital facilities and hence it is wise for the hospital management to employ appropriate steps to cushion its facilities from the enormous losses. Reliably, the engagement of an independent review organization will ensure the achievement of quality services which in turn will make promote the better relations between the hospital staff, managers and the patients. References Carroll, R. (2001). Risk Management Handbook for Health Care Organizations. New York: Jossey-Bass Publishers. Coventrywcs (2012).Telephonic Case Management. Crawford Company (2012). Broadspire Telephonic Case Management Fero, L. J., Herrick, C. A., & Hu, J. (2010). Introduction to Care Coordination and Nursing Management. Massachusetts: Jones & Bartlett Publishers. http://www.choosebroadspire.com/medmgmt/telephonecare.aspx http://www.coventrywcs.com/client-solutions/care-management/telephonic-case-management/index.htm Kahn, L., Aiello, J, Berdine, D. & Fox, H. (2009) “The use of telephonic case management to link a special-needs population with a primary care physician”. J Am Board Fam Med. Sep-Oct;22(5):585-7. Mullahy C. & Aspen Reference Group (1998). Essential Readings in Case Management. Jones & Bartlett Learning, 1998 Mullahy C. (2010). The Case Manager's Handbook. Jones & Bartlett Publishers. Powell, S. K., & Tahan, H. A. (2007). CMSA Core Curriculum for Case Management. New York: Lippincott Williams & Wilkins Publishers. Reilly M. & Markenson D. (2011). Health Care Emergency Management: Principles and Practice. Jones & Bartlett Publishers. Reilly, M. J., & Markenson, D. S. (2011). Health Care Emergency Management: Principles and Practice. Massachusetts, Jones & Bartlett Publishers. Read More