Introduction
Linda O’Donnell RN is the Director of Case Management and Ambulatory Care Clinics at Fairview Hospital, Cleveland Ohio; Georgianna Bennett RN is the Compliance, Appeals and Denials Coordinator at Fairview Hospital, Cleveland Ohio.

Correspondence concerning this article should be addressed to:
Linda O’Donnell, Director of Case Management
Fairview Hospital
18101 Lorain Avenue,
Cleveland, OH44111
(216) 476-7417
E-mail: Linda.O’Donnell@fairviewhospital.org

Georgianna Bennett RN Compliance, Appeals, Denials Case Manager
Fairview Hospital
18101 Lorain Avenue
Cleveland, OH44111
(216)889-6471.
E-mail: Georgianna.Bennett@fairviewhospital.org

Physician knowledge and awareness of health care reform is going to be more important than ever to ensure cost efficient quality care. Fairview Hospital Case Management Department has developed an education program for first generation medical residents to promote knowledge and awareness of maintaining high standards of compliance and quality while delivering healthcare.

CARE MANAGEMENT

Care Management Takes Lead Role In Educating Medical Residents

With impending healthcare reform, it is more critical than ever for physicians to keep current with new regulatory developments to ensure quality patient care, improved outcomes, and protection against penalties. Current practicing physicians do not fully comprehend the complexity of the conditions of participation for healthcare coverage. This can be an overwhelming endeavor in an environment of complicated rules, heightened regulations, and declining staff. Looking at cost efficiency, financial outcome, quality of care and the patient experience is a key role in the case manager’s job. To encourage awareness, Fairview Hospital Care Management staff have created a didactic education module on hospital based Care Management. Our intent is to promote knowledge and understanding to our physicians as they work side by side as a comprehensive team.

First year medical residents rotate through the Department of Care Management under the supervision of the Care Management Physician Advisor. Our goal is to promote knowledge and awareness of the financial and quality implications of healthcare delivery. An informed physician will be capable of using this knowledge to promote a climate of communication, transparency, and use of appropriate regulations to optimize the outcome for all concerned.

Each resident attends a two hour class each week for four weeks, led by RN Case Managers and our Physician Advisor. We begin the program curriculum by providing the resident with the overview of care management as a collaborative process that implement, coordinates, monitors and evaluates the options and services required to meet the client’s health and human service needs. It is characterized by advocacy, communication, and resource management and promotes good quality and cost effective interventions and outcomes. Our class syllabus includes four specific classes with each class consisting of formal and informal education, time for questions and answers, sample cases, and open discussion. The resident is given a list of objectives and a course evaluation where they can offer positive feedback to the department regarding this learning experience and how we can enhance it in the future.

The first class encompasses a discussion of our expectations and objectives, case managers’ roles and responsibilities, definition of discharge planning, length of stay, Diagnostic Related Group payments (DRG’s), levels of care, and routine processes and paperwork for dialysis, wound vacuum assisted closure care, physical and occupational therapy, etc.

Class two is based on the overall Utilization Review Management procedures and processes with an emphasis on RAC audits, our CM documentation program, payers, In and Out of Network providers, denials and appeals, and our Peer Utilization Committee. An Observation PowerPoint is presented with the medical residents presenting their own patients for discussion of appropriate criteria and status placement.

Class three is a presentation of InterQual Criteria®, how it is used at the RN level and then escalated to Physician or Physician Advisor level if appropriate. Key criteria points including Severity of Illness and Intensity of Service are taught. We demonstrate application of InterQual® criteria using the resident’s current in-hospital cases.

The last class of the series concludes with a field trip where the residents have an opportunity to visit a local community extended care facility. This is a learning tour allowing the medical residents to identify and view alternate levels of care offered in the facility, management of nursing home residents, and disease case management programs offered.

The Care Management Department encourages residents to shadow case managers and to incorporate them into their team on a daily basis to assist with getting the right patient in the right place at the right time using the right resources.

Current economic pressures challenge us to assure physicians of tomorrow are educated not only in the practice of medicine, but in maintaining high standards of compliance and quality while providing proactive, cost effective care. Fairview Hospital’s Care Management Department is up for the challenge!



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