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  • With the Balanced Budget Act of 1997, reimbursement will continue to change over the next 1-5 years affecting all facets of care delivery. The new reimbursement models provide for reduced reimbursement in the home health, long term care and ambulatory settings. It forces health care delivery systems to approach care delivery with a more integrated and “systems” approach. The focus needs to be on processes that streamline care delivery and integrate delivery processes Population management by the primary providers More emphasis on wellness and prevention to reduce the provider’s risk, particularly those associated with chronic illnesses Change in focus from episodic care to disease management, but understanding that there are limited, if any, outcomes of disease management due to the high enrollee turnover rate (25-30% VHA, Delliotte & Tuse), and enrolles are in a plan for about 2yrs. This makes it extremely difficult to measure outcomes. This requires integration of delivery models, involvement and participation of all stakeholders, cost control, and opportunities to identify new markets.

Pmm who we are Presentation Transcript

  • 1. Phoenix Medical Management, I:nc. Solutions for Hospital Case Management PHOENIX MEDICAL MANAGEMENT, INC.
  • 2. Phoenix Medical Management, I:nc. Solutions for Hospital Case Management
    • WHO WE ARE…
    • Phoenix Medical Management, Inc.
    • A national consulting firm exclusively dedicated to the design, implementation and management of hospital-based case management programs.
    • In business since 1994 with continuous financial strength and stability through quality business management.
    • Innovators of HCM v3.0 - the next generation of hospital case management models.
    • A team of full time and part time consultants and associates with executive and firing-line experience in hospitals, physician groups and/or PHOs/MSOs
  • 3. Phoenix Medical Management, I:nc. Solutions for Hospital Case Management
    • CORPORATE CAPABILITIES…
    • Case Management expertise encompassing
      • Leadership training
      • Regulatory and contractual utilization review
      • Breakthrough Transformation™
      • Program assessment
      • Staffing, skill mix, and orientation
      • Dashboard preparation for outcome reports
      • Documentation Improvement
    • Client projects across the country
    • Case management educational programs for medical staff, Board of Directors, & hospital associates
    • Interim leadership/management and project management to jump start new or transitioning programs
  • 4. Phoenix Medical Management, I:nc. Solutions for Hospital Case Management
    • OUR PHILOSOPHY OF BUSINESS…
    • Greater results are achieved through collaboration
    • Service excellence through people, processes and information enable us to exceed client expectations
    • We seek to evolve with our customers by understanding their needs over time
    • Our goal is to become a strategic partner not a vendor of consulting services
  • 5.
    • The Patient Protection and Affordable Care Act and the reconciliation bill are now law, and together, they will trigger sweeping changes and disruptions — some rather quickly and some over many years
    • Baby boomers > Savvy consumers
    • Erosion of public trust
    • Value based purchasing
    • Value added services to improve hospital efficiency
    • Transitions of care internally and externally
    • Reimbursement shortfalls resulting from readmissions and HACs,
    • Increased scrutiny from oversight agencies: MAC, RAC, ZPIC, et al
    • Operational complacency and hollow accountability
    • Practice variations: “The biggest cost driver is when the physician puts pen to paper”
    Phoenix Medical Management, I:nc. Solutions for Hospital Case Management CHALLENGES DRIVING HOSPITAL CASE MANAGEMENT TRANSFORMATION…
  • 6. WHAT WE DO…Work With You To:
    • Design an effective infrastructure
    • Develop an operating plan
    • Identify priorities and timelines
    • Facilitate execution of your plan
    • Recruit, educate and train case management staff
    • On site project management; interim leadership
    Phoenix Medical Management, I:nc. Solutions for Hospital Case Management
  • 7. WHY WE DO IT…
    • CHALLENGE: In the future, hospitals will have to deliver a coordinated episode of care for the same expense as their cost per case in 1997!
    • FACT: Costs per case will not be significantly reduced without significantly reducing the volume of clinical resources used per case!
    Phoenix Medical Management, I:nc. Solutions for Hospital Case Management
  • 8. HOW WE DO IT…
    • Employ data to drive process improvement
    • Align performance expectations of the case managers with the hospital’s strategic goals
    • Establish a real time link with the physicians
    • Integrate contractual, regulatory & payer requirements
    • Engage customer by offering value-added service
    • Quantify system barriers and obstacles
    • Involve the entire hospital
    Phoenix Medical Management, I:nc. Solutions for Hospital Case Management
  • 9. HOW WE DO IT… Phoenix Medical Management, I:nc. Solutions for Hospital Case Management BREAKTHROUGH TRANSFORMATION™ HCM v1.0 CLINICAL NURSE PRACTICE MODELS HCM v2.0 FUNCTIONAL MODELS HCM v2.1 FUNCTION MODELS/CONSOLIDATED ROLES HCM v2.2 FUNCTIONAL MODELS/INTEGRATED ROLES HCM v3.0 OUTCOME MODELS An outcome model of hospital case management is a collaborative process between the case manager and the physician, the patient, and the clinical team to proactively advocate and support the patient’s progression-of-care through the hospitalization and into the community.
  • 10. HOW WE DO IT…methodology:
    • 1. GET EVERYONE ON THE SAME PAGE
    • Convene hospital and medical leadership to present components of hospital case management, to promote understanding of basic principles, and to secure consensus that the basic principles are in harmony with organization’s vision, goals and values.
    • 2. ORGANIZATIONAL ASSESSMENT/READINESS EVALUATION
    • Interviews, focus groups, observations and document review, and analysis of performance outcomes.
    © Phoenix Medical Management, Inc. Slide
  • 11. HOW WE DO IT…methodology:
    • 3. PRELIMINARY PLAN/RECOMMENDATIONS
    • Based on assessment and serves as basic foundation for the design of a strategic plan
    • 4. IMPLEMENTATION PLAN
    • Collaborative endeavor with design team to identify and prioritize design elements
    • 5. EXECUTION, EDUCATION AND TRAINING
    • On site support, conference calls, hospital wide preparation and case manager orientation
    © Phoenix Medical Management, Inc. Slide
  • 12. TRANSFORMATION GOALS © Phoenix Medical Management, Inc. Slide
    • More economical skill mix and broader role eligibility.
    • Real time physician:case manager partnerships.
    • Value-added workflow activities.
    • Case management across the entire continuum, from access to transition
    • Focus on progression-of-care activities: “Plan for the stay; plan for the day; plan for the way.”
    • Early identification of post acute needs.
    • Use of data to drive change in practice and delivery of care processes.
    • Objective dashboard to measure case management success.
  • 13. EXPECTED OUTCOMES Phoenix Medical Management, I:nc. Solutions for Hospital Case Management
    • Lower costs per case (severity adjusted)
    • Higher case mix index per physician
    • Reductions in length of stay and readmissions
    • Reduction or elimination of payer denials
    • Reduction of avoidable days (the most expensive service the hospital provides!)
    • Higher patient and physician satisfaction rates
    • Increase in CMI
    • Improvement in core measure compliance, POA documentation, and medical necessity determinations.
  • 14.
    • HCM v3.0: “An invasion of armies can
    • be resisted, but not an idea
    • whose time has come.”
    • Victor Hugo, 1852
    • Contact PHOENIX today!
    • 888.671.6505
    • [email_address]
    Phoenix Medical Management, I:nc. Solutions for Hospital Case Management