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

Authors’ Note
This book is a sequel to The Case Management Sourcebook: A Guide to
Designing and Implementing a Centralized Case Management System,
authored by Cherilyn G. Murer, J.D., CRA, President, and Lyndean Lenhoff
Brick, J.D., Senior Vice President, Murer Consultants, Inc., in 1997. This
updated case management workbook reflects a number of important regulatory
changes that have occurred in the past 13 years, as well as the new
landscape of healthcare reform.
As with the 1997 publication, Murer Consultants believes this book will
serve as an important resource for case managers, administrators, physicians
and others who play a role in the case management process