Turn the MCO’s case manager from foe to friend
Try these tips on working the managed care system
Education managers across the nation are witnessing a revolution in health care as managed care companies gobble the insurance market faster than Pac Man.
Experts predict these changes will add to home care agencies’ paperwork and increase the frustration among some employees who have trouble adapting. But they say you can ease the transition through inservices and educational workshops that teach nurses how to most effectively deal with case managers.
The managed care organization’s case manager is the major gateway between the MCO’s money to pay for services and your agency’s ability to give patients the best quality care.
A Tennessee home care agency had one experience that demonstrated how case managers and MCOs, although tough, are not heartless.
"There was a patient who had a motor vehicle accident and was paralyzed from the neck down, with little movement of the upper extremities," recalls Charleace Warren, RN, vice president of professional services, of Homecare Health Services of McKenzie, TN, a for-profit agency that serves a 24-county rural area of western and middle Tennessee.
The patient was young, and he and his wife were uneducated and had unhealthy lifestyles. They were on Tennessee’s equivalent of Medicaid, called TennCare, which two years ago was turned over to private MCO’s through contracts. (See story on TennCare, p. 27.)
"The patient wanted to stay home," Warren says. "He had been in hospitals and rehabilitation and was bounced from pillar to post and hadn’t been home in months."
To make matters worse, she adds, the patient was incontinent and had a huge bedsore. "He wasn’t real cooperative because he was angry about everything."
The MCO approved only three visits, and in that time the home care agency was supposed to teach his wife how to turn him, exercise him, how to dress and clean his wound, and perform other activities.
"They approved physical therapy, but we fought and fought for more skilled nursing visits because there were so many complicated skills that he and his wife had to learn," Warren emphasizes.
"We pushed so hard that the MCO sent their case manager out to visit the patient," she adds. "After her visit, she felt like he needed more services than we were asking for, and we got all the care — 12 to 14 nursing visits, plus the physical therapy — approved for him."
Five tips to coping with case managers
Warren and other experts offer these guidelines on how you can teach your case managers and other nurses about dealing with managed care case managers:
• Invest time and energy in learning about the managed care organization in your market.
"Make sure your agency has the most up-to-date access to information," says Nancy Harvey, RN, BSN, senior consultant with Healthcare Concepts of Memphis, TN, which is a private home care consulting firm that provides educational programs, publications, and executive searches.
Harvey recommends that management then collect information about the organization’s case managers to identify what each case manager prefers in documentation and follow-up. "Make sure your agency is meeting the case manager’s information needs."
Also, teach staff what the case manager’s role is so there won’t be any misunderstandings about what to expect, experts advise.
"It’s real important to talk about the role of the case manager in the managed care organization," says Jennifer Jenkins, MBA, RN, CNAA, vice president of Healthcare Concepts in Memphis, TN.
Jenkins suggests you discuss their purpose, what they are trying to do, and how your agency can help them achieve their goals. "Too often there are adversarial relationships between case managers and home care agencies," she adds. "There has to be greater understanding."
One way to achieve this, Jenkins says, is to have your staff meet with the case manager and other representatives of the MCO when this is possible.
Warren’s advice is simply, "You have to know what the MCO wants, just like you have to know what Medicare wants."
• If possible, choose one nurse to deal with the case manager, and make sure he or she has good people skills.
"They have to be able to communicate in a friendly and professional manner and not take things too personally," Harvey explains.
Harvey prefers that the nurse chosen for the job have at least four years of experience in the home health care field and that he or she understand the balance between level of care and payer sources.
Warren says it’s better to have one person in the office who is calling the MCO every day for updates. "The person who is working with the case manager should not be the person who’s dealing with the patient," she insists.
Also, Harvey says, the nurse should be tactful, self-directed, and detail-oriented. By self-directed, Harvey means that the nurse should know when and how to follow up on a case and should look at ways to meet the extensive demands for information. She explains, "They should be able to go to the supervisor and say, They want us to give them this type of information every week, and we’re not doing it at this time, so how can we do it?’"
While it’s important for the nurse to get along with the case manager, he or she also needs to be able to relate to the staff nurses who are coping with the changes.
"The nurse should be able to be a partner in the provision of care with the staff providing the care and with nursing supervisors," Harvey says.
• Sell yourself to smooth the way for a better agency-case manager relationship.
"You basically have to sell yourself and your competency to that person on the phone," says Sharye Hardesty, RN, BSN, MBA, vice president of clinical services for Supra Management Corp. in Metairie, LA. The private company consults with home care agencies, providing educational programs and research.
"You have to maintain good and frequent communication, and don’t give them information that’s meaningless; you must have something good to report," Hardesty adds.
Harvey says it’s possible to become too friendly with the case manager, but a little personal exchange can be helpful. "Different regions have different ways of communicating. In the South, you might talk about your family; up North, you might discuss the sports scene," she says.
"I just keep the word "professional" in there because you don’t want to get too chummy; you want to be respectful," Harvey adds.
One good method to getting what you want from a case manager is to convince him or her that you also want to keep health care costs down, but in this particular case, it would be better to approve more visits, experts say.
"Once you prove to the case manager that this is really better for the patient then the case manager is a patient advocate," explains Linda Prima, network director of Supra Management Corp. of Metairie, LA.
"They are concerned about the dollars, but they will approve extra visits if necessary," Prima adds.
Put yourself in the case manager’s shoes, Warren advises.
"I’ve been dealing with case managers for private insurance companies for years," Warren relates. "And I basically understand where they are coming from."
Warren’s chief advice is to "not ask for the moon." Forget the old world ways, she says. "Don’t ask for two months of care like you normally do when you have a Medicare patient; don’t start out asking for daily aide visits if there’s a caregiver in the home.
"Think about what’s medically necessary, the minimum — not the maximum."
• Remember that it takes team work between the case manager and home health agency.
"At the home health agency it’s the contact person who clarifies what the case manager wishes," Harvey says.
The contact person also helps the staff understand how the patient care is limited to services and numbers of visits approved by the managed care company. "The contact person explains what they must accomplish in a set period with certain criteria," she adds.
Home care agencies might change their documentation to accommodate the needs of an MCO, Harvey says. For example, they could use more care maps and outcomes tools that help nurses identify the objectives of every visit.
"We’re seeing changes in not only the philosophy of providing care but also in how we are structuring our care and thus how we are documenting our services," Harvey explains. "It’s kind of like a domino effect."
Homecare Health Services has had cases where the agency has had to fight to extend approved visits for a patient, Warren says. "But this is fighting in such a way that you’re explaining why you need this so you don’t alienate the case manager."
Warren’s approach might go something like this: "If you approve this, it will be less costly than if you don’t because if you don’t, the patient will end up in the hospital again."
Education managers might instruct their nurses to forget their fears of health maintenance organizations and instead look at case managers as partners, Prima suggests.
"The case managers are really your friends," she says. "The reality is that they have to hold down health care costs, and you are an ally to assist them in holding down health care costs."
• Show your staff how managed care companies and case managers can help your agency become better and more efficient.
Warren believes that managed care’s focus on cost-cutting has made her home care agency more efficient. "Everyone does some visits that might not really accomplish the agency’s goals," she says.
"You get sidetracked: Maybe the patient’s crying about something or you’re not getting to teach the wound care like you want to teach. So this is making us more focused on our goals," Warren adds.
Homecare Health Services’ staff has had experiences in which a patient and family members insist they cannot do a certain task. So the agency tries to convince the case manager that more visits are needed. But it might turn out that the case manager was correct all the time, and the family really was ready.
"The family may tell us they can’t do it, but when the case manager calls them, they say, Yeah, we can do this just fine,’" Warren recounts.
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