Knowledge of home care key for case managers
Managing physician interactions is key
Home care may be a vital component of the health care continuum for case managers. But that doesn’t mean that home care is vital to physicians, despite the important role they play in this area. "It’s a real quandary," says veteran home care consultant Elizabeth Hogue, JD, in Burtonsville, MD, who says that many case managers lack a real understanding of this area.
If the case manager is trying to get a patient referred for home care or get a particularly difficult and complex patient cared for — such as a chronic obstructive pulmonary disease patient or a congestive heart failure patient — one of the things he or she has to manage is physicians and physician interaction, says Constance Row, executive director of the American Academy of Home Care Physicians (AAHCP) in Edgewood, MD.
According to a recent study by the Health and Human Services’ Office of Inspector General (OIG), physicians are heavily involved in identifying the specific home health services their patients need. More than half say they work with hospital staff and home health agencies to determine the services patients will receive. Many also are involved in finalizing the initial plan of care.
At the same time, the OIG reports that physicians have a limited knowledge of key Medicare rules regarding home health and are very uncomfortable with the new prospective payment system (PPS). While 83% of physicians know that Medicare expects them to ensure that only medically necessary services are on the plan of care, only 48% say they are able to accomplish that.
"Not only is it difficult to get doctors to devote the time it deserves, but even when physicians say they understand home health, they often do not," Hogue says. Instead, doctors often rely on others to help them understand the eligibility criteria on a case-by-case basis.
Notably, doctors report that hospital staff, such as discharge planners, are by far the most important source of information and guidance on home health (76%). Another 55% seek guidance from home health agencies. However, very few rely on guidance from Medicare (11%) or periodicals (16%).
That makes it imperative for case managers to create opportunities to educate physicians about home health, Hogue says. There is often a disconnect between the very real need for physician understanding of home health and the mechanisms available for educating them, she adds.
Worse yet, the variety of tools that typically are used often, such as meetings of medical staff, do not work very well. "The only thing that works is one-on-one interaction," she asserts. That means case managers must use every opportunity to create those conditions.
Physicians must know the answers to the most frequently asked questions, Row says. Those are: What am I supposed to do and how am I supposed to do it? How is this the same or different from the way it was prior to PPS? In addition, she says, there are typical fact situations that doctors must be familiar with.
"If case managers run into a situation where physicians do not know or are resistant to getting involved with home health agencies, the only way to overcome that is to know what they need to know to do to get them there," Row says.
If physicians want a primer in this area, the AAHCP has a booklet, Making Home Care Work in Your Practice. "If case managers are able to use that information in answering physician questions, they probably will be doing as much as they can do," Row says. (To order the booklet, go to www.aahcp.org.)
According to Hogue, the real problem runs even deeper. She says many case managers often have viewed home care as a stepchild. Under cost-based reimbursement, the only thing case managers simply had to do to place a patient in home care was call an agency.
As a result, they never had to learn about eligibility criteria. "We almost have a whole additional group of people who need to be educated as well," she contends.
The way to begin an education process for case managers is to have credible providers come in and sit down to explain eligibility criteria for various payer sources, Hogue says. "That is where I would start if I were a case manager," she says.
That is often easier to accomplish then bringing physicians to the table. "We have had better luck with that then we have had with doctors," she says. "Case managers are much more amenable to sitting down and spending the necessary time on this issue."
According to Hogue, an understanding of home health is becoming increasingly important for case managers because some health policy analysts are beginning to develop a model of community-based health care that puts home care agencies at the center of the delivery system.
This creates significant challenges for case managers, because case management is a relatively new discipline and the role of case managers in home care is very poorly defined. The role of the hospital-based case manager is still very different from a home health agency’s employment of a case manager, says case management consultant Louis Feuer, MA, MSW, in Pembroke Pines, FL.
Often, the hospital-based case manager is not involved with the patient after the discharge, and the scope of his or her involvement with the patient is very much controlled by how long the patient is in the hospital and the severity of the illness, he says. Alternatively, the payer-based case manager may oversee all of this operation from the hospitalization and discharge to what happens in the home care setting.
Home health case managers typically have to work with the hospital case managers because they may not pick up that case until the day of discharge, Feuer says. That makes it likely that the patient has more than one case manager.
According to Feuer, while home health agencies often use the title case manager, the question is whether they have a licensed or certified case manager in their home health agency. In practice, there is a strong possibility that many of these agencies are not funding a full-time case manager, he says.
Feuer reports that hospitals currently are using a variety of methods to establish this function. Years ago, they often accomplished this through the social work departments. But some of those departments literally changed their names to case management departments or continuing care departments. "Their responsibility is to arrange for appropriate quality care after the patient is discharged from the hospital. The problem is that their involvement after the patient leaves the hospital is often zero," he says.
That is the reason the third-party payer industry has employed so many case managers, Feuer says. It also is the reason for many of the conflicts between hospital-based case managers and payer-based case managers.
"They are often looking at this from a very different perspective," he says. "The payer-based case managers do not have the opportunity to see the patient face to face because they are sitting in the corporate office in Hartford."
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