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Comprehensive Care Management Comprehensive Care Management is a comprehensive medical management company that helps control costs by enhancing efficiencies and quality of care for health plans. Comprehensive Care Management offers a full scope of services from pre-certification and case management, to disease management, phone triage, and statistical/clinical consulting for group health plans. Comprehensive Care Management, located in Baton Rouge, La., serves clients statewide, as well as nationally, and has a total membership of 30,000. It has served both small and large groups, as well as public groups, among them the employees of City of Baton Rouge/Parish of East Baton Rouge. The value of Comprehensive Care Management’s services is measured in its positive return on investment and track record of successfully controlling health care cost increases, in some instances actually reducing costs over several years. Our success is rooted in our unique approach to and understanding of the healing process, which is rooted in our tradition. Comprehensive Care Management is a service of Calais Health, and is owned by the Franciscan Missionaries of Our Lady (FMOL). We are thus rooted in the traditions of FMOL and approach medical management within a mission-driven, values framework. We understand that the healing process is both a clinical and personal experience, and that the interplay between providers, patient, family and community all contribute to health and recovery from illness. ACUTE CARE CASE MANAGEMENT PRE-ADMISSION CERTIFICATION Pre-Admission Certification is the process in which a nurse reviewer evaluates the treating physician's request and proposed plan for inpatient admission to an acute care hospital. Using established medical and length-of-stay criteria, our reviewer evaluates the treating physician's documentation on each proposed admission in regards to:
The overall objectives of this evaluation process are to assure:
Continued Stay Review is the process in which the nurse reviewer evaluates inpatient hospitalizations at designated intervals until discharge occurs. Using established medical and length-of-stay criteria, our reviewer evaluates hospitalizations to determine:
The overall objectives of the evaluation process are to assure:
DISCHARGE PLANNING Discharge Planning is the process in which the concurrent nurse reviewer coordinates and expedites transfer of patients and their treatment needs from hospitalization to an alternative, more cost-effective setting. Alternative settings for individuals are determined by their treatment needs. Alternatives considered during this selection process include such things as:
The overall objectives of the discharge planning process are to assure:
RETROSPECTIVE UTILIZATION REVIEW Retrospective Utilization Review is the process in which a nurse reviewer evaluates inpatient hospitalizations that were not reviewed during the admission. This frequently occurs in an emergency situation, or when a member or provider fails to notify the health plan before the admission. Using established medical criteria, the reviewer evaluates the medical documentation on an admission to determine:
The overall objectives of this evaluation are to:
COMPREHENSIVE CARE MANAGEMENT Our Comprehensive Care Management program consists of two processes: Case Management and Disease Management. The effectiveness of these two processes is linked to the foregoing Health Data Analysis as well as our ability to put in place ongoing triggering mechanisms that identify patients who would benefit from Care Management. Through our Case Management Department, we systematically and proactively identify high-risk patients and assess opportunities to coordinate and manage total care. Medical, psychosocial, cultural, nutritional, spiritual, and personal needs of the individual are addressed especially those who are at high risk for complications related to chronic disease. Key case management responsibilities include assessment, problem identification, outcome identification, as well as planning, monitoring, and evaluating case management interventions. The Case Manager becomes a facilitator, coordinator, counselor, and patient advocate to ensure that the best quality of care available is delivered to individual patients in the most efficient and effective manner possible. Disease Management has proven to be a successful method of managing costly patients with chronic diseases. Disease-specific management focuses on the etiology of the condition that is pertinent, promotes self-management, and coordinates care that may be delivered in a fragmented fashion by disparate providers. We can either work with local providers who may have educational or disease management programs in place, or we can use our own. This method of care management is a proactive and concurrent approach to promoting wellness and self-care. Specific areas of disease management focus include:
Expected outcomes of the Care Management program are:
Cooperation with the plan administrator is essential
in achieving success in the Comprehensive Care Management Program as an ongoing process
of identification and referral to Care Management must be established.
This is best accomplished through routine claims downloads, or for an
additional fee, Comprehensive Care Management Systems can consult with the administrator
to put these processes in place within the administrator’s operations.
Likewise, working with the plan administrator, Comprehensive Care Management Systems
is able to provide routine reports that document Care Management activities,
savings, and patient results.
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