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Authors' Note | p. xi |
Foreword | p. xiii |
Acknowledgments | p. xv |
Introduction: A Genesis of Case Management | p. xvii |
About the Authors | p. xxi |
Who Is Responsible for Case Management? | p. 1 |
Overview | p. 1 |
What Is Uncompensated Care? | p. 2 |
Moving the Patient in a Timely Manner | p. 3 |
The Use of the Emergency Department | p. 5 |
The Essence of Effective Case Management | p. 6 |
Structure | p. 7 |
Physician | p. 8 |
Nursing | p. 8 |
Case Managers | p. 9 |
Administration | p. 9 |
Everyone | p. 10 |
Case Management Is Truly Everyone's Responsibility | p. 10 |
Financial Incentives | p. 11 |
Aligning Incentives: Current Payment Structure | p. 11 |
The Physician Payment | p. 11 |
Hospital Payments | p. 12 |
Post Acute Venue Payments | p. 12 |
Fraud and Abuse | p. 13 |
Recovery Audit Contractors Audits | p. 13 |
Future Payment Structure | p. 14 |
Bundling Physician and Hospital Payments | p. 14 |
Post Acute Care Bundling Plan | p. 15 |
Post Acute Care Bundling Proposal Details | p. 16 |
Industry Reaction | p. 17 |
The Watershed Years of the American Healthcare Delivery System | p. 21 |
The Watershed Years | p. 21 |
The Barrier Defined | p. 22 |
Healthcare Reform: 2010-A Major Watershed Year | p. 24 |
Key Obstacles in Reducing Length of Stay | p. 27 |
Cajoling Can No Longer Be the Primary Methodology for Dealing with Physicians | p. 27 |
The Largest Obstacle | p. 27 |
Cultural Change | p. 28 |
Social Issues | p. 28 |
Preference for the Intensive Care Unit | p. 29 |
Consulting Physician | p. 29 |
Attending Physician in the Role of Quarterback | p. 30 |
How to Deal with a Difficult Physician | p. 30 |
Other Obstacles | p. 31 |
Obstacle: Physical Plant | p. 31 |
Obstacle: Monitoring Equipment | p. 32 |
Obstacle: We Wait and Wait for Approval | p. 32 |
Obstacle: Staffing Shortage | p. 32 |
Is the Post Acute Venue Ready? | p. 33 |
Slow Down, You're Moving Too Fast | p. 34 |
Opportunities for Effective Use of Post Acute Venues | p. 37 |
Venue Management | p. 37 |
Centralized Case Management System | p. 38 |
Post Acute Venues and Their Roles in the Continuum | p. 43 |
Introduction: Post Acute Venues | p. 43 |
Long-Term Acute Care Hospital | p. 44 |
Overview | p. 44 |
Regulatory | p. 45 |
Length of Stay | p. 47 |
Benefits and Conditions | p. 48 |
Physician Coverage | p. 49 |
LTACH Payment Structure | p. 50 |
Comprehensive Inpatient Rehabilitation Hospital/Unit | p. 50 |
Overview | p. 50 |
New Coverage Criteria | p. 51 |
Three-Hour Rule | p. 53 |
Criteria for Admission | p. 53 |
60 Percent Rule (Previously the 75 Percent Rule) | p. 54 |
Physician Coverage | p. 56 |
Medical Directorship-20 Hours per Week Rule | p. 56 |
Product Line Specialization | p. 57 |
Inpatient Rehabilitation-Payment Structure | p. 57 |
Skilled Nursing Facility/Unit | p. 58 |
Overview | p. 58 |
Admission Criteria | p. 58 |
Skilled Nursing Physician Care | p. 59 |
Skilled Nursing Payment Structure | p. 59 |
The Difference between Comprehensive Inpatient Rehabilitation and Skilled Nursing | p. 60 |
Outpatient Rehabilitation and Home Health | p. 61 |
Outpatient Rehabilitation | p. 61 |
Home Health | p. 62 |
Hospice | p. 62 |
Case Management at the Epicenter of an Integrated Health System | p. 65 |
The Epicenter of an Integrated Health System | p. 65 |
Models | p. 66 |
The Hybrid Model of Case Management | p. 66 |
Seamless Protocols | p. 67 |
Discharge Triggers | p. 68 |
Case Studies | p. 69 |
Appropriate Movement of the Patient | p. 69 |
Diagnosis-Related Group Review | p. 77 |
Overview | p. 77 |
Major Diagnostic Category | p. 77 |
Diagnosis-Related Groups | p. 79 |
With or without MCC and CC | p. 80 |
Projecting the DRG | p. 86 |
The Sticky Note | p. 86 |
Assigning a Different DRG | p. 87 |
Meaningful Data | p. 91 |
Meaningful Data | p. 91 |
Efficacy of Data | p. 91 |
Electronic Medical Record | p. 92 |
Benchmarks | p. 93 |
Conclusion | p. 97 |
Examination Questions | p. 99 |
Class Exercises | p. 101 |
Exercise 1: Develop a Venue Inventory Worksheet | p. 101 |
Exercise 2: Identify the Parameters of Case Management in Your Organization | p. 101 |
Exercise 3: Key Obstacles | p. 102 |
Exercise 4: Opportunities for Effective Use of Post Acute Venues of Care | p. 102 |
Exercise 5: Case Management in a Multivenue Setting | p. 102 |
Glossary | p. 103 |
Acronyms and Abbreviations | p. 107 |
Index | p. 109 |
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