Case Management Program

Case Management Program Scope of Services

Mission Statement: To assist physically impaired individuals throughout the region to realize their optimal level of functional independence, productivity, social adjustment, and self-esteem.

Our Vision: The Standard of Excellence in Rehab Services

Our Values: Service, Integrity, Respect, Excellence, Humility, Accountability, Best

Purpose: The purpose of the Rehab Case Management Program is to promote quality of care cost effective patient outcomes and efficient resource utilization, while meeting the emotional needs of the person served and families and assuring a complete adjustment to and an understanding of the injury, illness or disability and to assist with making a smooth transition into the hospital and back into his/her home and/or community.

• Patient Experience – Anticipate the person served needs and exceed expectations in a compassionate manner.
• Improved Outcomes – Provide excellence by moving the patient through the continuum of care.
• Manage or Reduce Costs – Maximize the use of available, finite resources to meet the current and future needs of the person served.

The Case Management Program under the general supervision of the Director of Case Management, in collaboration with the Medical Director, Attending Physicians, treatment team and external entities, plans and coordinates the admission of and discharge of the persons served.

Case Management is responsible for the coordination of services to the person served, their family and/or significant others including emotional support, advocacy, community resource integration and financial assistance/information.
Activities are accomplished through pre-admission review, concurrent and retrospective medical record reviews and effective discharge planning.

The Case Management Program team members have the knowledge of Medical and Rehabilitation Terminology and demonstrated knowledge of:

• Case Management principles and methodology
• Knowledge of levels of care including acute care, critical care, acute rehab, skilled care, sub-acute care, outpatient, home health, day treatment.
• Government, county, private and workers compensation funding sources.
• Eligibility criteria
• Criteria for determining level of care and knowledge of managed care including Medicare managed care programs (HMO, PPO, PSO).
Demonstrated ability to:
• Communicate effectively with health care professionals and external case managers.
• Identify obstacles to persons served progress and barriers to discharge.
• Problem solve with the rehab team to remove barriers.
• Maintain professional relationships; work effectively and collaboratively with other members of the rehab team.
• Participate in Continuous Quality Improvement activities.
• Actively pursue continuing education and training opportunities in case management.
• Ability to maintain knowledge regarding standards of care, case management/utilization principles and approaches, social services and discharge management.
• Ability to maintain confidentiality regarding the persons served medical record.
• Understand insurance and payer requirements.
• Demonstrate the knowledge and skills necessary to provide care based on physical, motor/sensory, psychosocial, and safety appropriate to the age of the person served.

Staffing Plan:
General staffing requirements are reviewed at least annually as part of the budgetary process. Requests for staffing changes are based upon review of trend Patient to Integrated Case Manager Ratio’s, productivity data, requests for service, scope of work required and the needs of the department’s customers and the organization.
In general, the staffing plan includes:
1 FT Director of Case Management
1 RN Case Manager (FT)
1 SW Case Manager (FT)
4 RN Admission Liaisons (FT)
1 Admission Specialist (FT)
3 Financial Advocates/Insurance Specialists (FT)
1 Case Management Administrative Assistant (PT)

Scope of Service:
Populations served and admission considerations
In providing care, consideration is given to the unique needs of each patient population served. Our primary population consists of adults (ages 18-65) and geriatrics (ages older than 65). We can admit pediatric patients (school age and above beginning at age 5) but this is a limited number of our admissions. An interdisciplinary team coordinates the efforts to enable persons served to reach their maximum potential. Persons served at SIRH may have impairments as the result of: stroke, brain injury (traumatic or non-traumatic), spinal cord injury (traumatic or non-traumatic), complex orthopedic conditions, amputation, neurological disorders, multiple trauma and/or medically complex conditions resulting in a debilitated state with need for inpatient rehab facility admission.
Conditions that may exclude someone from admission to SIRH include: no community discharge plan/or resources, psychiatric issues preventing cooperation with the rehabilitation treatment team plan, and/or ventilator dependence. Patients requiring IV chemotherapy agents and/or radiation and pediatric patients from age 5 to 12 are evaluated for appropriateness of admission on an individual basis by the interdisciplinary clinical admissions team that includes the Director of Inpatient Therapy, Nursing Director, Medical Director, Admission Liaison, Director of Case Management and Pharmacist.

Setting:
Acute Inpatient Rehabilitation Hospital
Sub-Acute level of care

Days and Hours of Service:
Monday – Friday 8:00 a.m. – 5:30 p.m.
Admission Office – 812-941-6122
Case Management Office – 812-941-6138
Coverage for the department is available for emergency situations seven days/week via the hospital’s switchboard operator. (812-941-8300) Admission Liaisons provide coverage on weekends by completing rounds at referring hospitals and facilitating admissions on weekends and holidays. Admissions may be scheduled 7 days/week preferably before 8:00 p.m.

Frequency of Services:
Team walking rounds occur weekly
Follow up with patient/family/significant other/other stakeholders weekly

Payer Sources: (not to be all inclusive)
Anthem Blue Cross/Blue Shield Products
Aetna
Cigna
Healthy Indiana Plans
Humana
Medicare
Medicare Replacement Plans
Kentucky Medicaid
Indiana Medicaid
Self Insured Employers
Tricare
United Health Care
Veterans Affairs (VA)

Fees:
Potential Admissions: Fees are determined by the 3rd party payer (insurance) based on the individual person’s served benefit plan. The co-pay and out of pocket expense and responsibility is discussed with the person served and/or family prior to admission by the SIRH admission liaison.* The Case Managers discuss with the person served and/or family the discharge planning needs, durable medical equipment and other after care benefits and expenses.

There are no direct fees or additional fees associated with Case Management Services provided as this is covered as part of the rehabilitation stay.

*Refer to the SIRH Written Disclosure Statement

Referral Sources:
SIRH accepts referrals from and admits from all area – local and regional hospitals, nursing facilities and if appropriate home. Referrals are also accepted from physician offices, family members, insurance case managers, etc.

Services Provided:
In collaboration with the treatment team, attending physician, and external entities, the Case Management Department is responsible for coordinating and directing the planning, organization, evaluation, and follow-up of patient care.
Responsibilities include:
-Conducting the pre-admission screening, intake and evaluation for rehab potential and appropriateness and placing in the appropriate program IRF vs sub-acute level of care.
-Initial reimbursement forecasting by determining the impairment code, case mix group, anticipated length of stay. -Obtaining prior authorization, verification of benefits, insurance coverage and payer expectations along with concurrent reviews
-Scheduling the weekly interdisciplinary walking rounds and family conferences as needed.
-Identifying person served/family/social/emotional issues to consider in establishing an appropriate discharge plan and optimal stay for the person served.
-Evaluating documentation of person’s served progress, continued stay and level of care needed.
-Directing the discharge planning process.
-Promoting the utilization of resources in compliance with the external review criteria and payer expectations.
-Facilitating exchange of pertinent information though the continuum of care.
-Tracking of person’s served based on discharge disposition.

The Case Management Program shares information about the scope of services with persons served, families/significant others, in accordance with the choices of the persons served, the facilities, physicians and other referral sources, third party payers, other relevant stakeholders and the general public through the SIRH web site (www.sirh.org) and the Patient Handbook.