Care Management is:

o All care providers working in concert, including the patient, so that the care of the patient is well coordinated.

o Ensuring that the patient is accessing care at the right time, in the right place, and for the right cost.


Spectrum Health Care Management is part of the Access Management group. This group includes 4 departments: Patient Registration, Denials Management, Bed Management, and Care Management

Goals of Care Facilitation

o Proactively identify patient risk factors - at or before admission

o Promote quality care delivery across the continuum

o Implement strategies to assure that the patient receives:
   - the right care - in the right setting - at the right cost

o Facilitate discharge planning

o Provide comprehensive psychosocial assessment and counseling

o Improve the quality of information integration with the primary care physician and next level of care

o Assure alignment of patient goals and treatment plan with the interdisciplinary health care team

o Secure benefit coverage for patients and provide payers with accurate updated medical information


Care Management Mission

"To facilitate, either directly or indirectly, high quality, cost efficient, seamless care for patients and families which promotes individual and community health and fosters smooth transitions through the continuum of care."


Team Roles and Responsibilities

What do members of care facilitation teams do?

Nurse Care Facilitator Role:

a) Coordinate care with physicians (primary care physicians and specialists) and other disciplines

b) Assure patient/family involvement in decision-making

c) Follow up on physician orders (labs, radiology, consult reports) and verify follow through in a timely manner

d) Proactively plan for discharge - setting a target length of stay and working within that or implementing strategies to impact length of stay (assure pathway initiated if one applies)

e) Address barriers to patients moving through an inpatient episode of care, determining options for the next level of care - i.e. home with home care, sub-acute care, assisted living, etc.

f) Identify system barriers which negatively impact quality patient care or length of stay

g) Provide referrals, medical/clinical information to and make arrangements for home health, DME, medical supplies or post-acute care facility.

h) Obtain pre-certification, complete admission and concurrent review, communicate with payors - utilizing Interqual Criteria for a medically complex patient population.

Medical Social Worker Role:

a) Assessment of patient/family psychosocial needs

b) Adaptive/supportive counseling and crisis intervention around issues of adjustment, substance abuse, lifestyle/behavior change, stress management, body image changes, grief and loss.

c) Coordinate clinical issues with the care facilitator and hospital personnel and make recommendations to the team regarding treatment to help patient achieve optimal level of functioning and health.

d) Link patient/family with most appropriate resources - i.e. disability, medication assistance, outpatient counseling, support groups, etc.)

e) Facilitate patient nursing home placements and less medically complex home health care.

f) Assist patients, family, care givers and hospital personnel with decision making about ethical issues.

g) Intervene in questionable cases of patient competence and need for guardianship and legal decision-maker.

Utilization Review Specialist:

a) Assess medical necessity based on a standard set of criteria - Interqual Intensity of Service, Severity of Illness.

b) Serve as a consultant regarding payor criteria for medical necessity.


History of Care Management Group

One of the original objectives of forming West Michigan Physicians Network (WMPN) and ultimately Spectrum Health Physician Hospital Organization (PHO) was to increase physicians' ability to impact/improve the process of care delivery. In the past, care management processes on the Spectrum Health campuses have primarily been driven by the hospital or health plan. Given the fact that the physician community has traditionally lacked the time, resources and infrastructure to effectively lead this process, a system care management model was probably the next best alternative.

During 1998, WMPN and Spectrum Health PHO made a significant amount of progress in establishing themselves as organizations. Probably the most powerful and yet currently underutilized portion of the PHO infrastructure is the Care Management Group (CMG), which is structured to serve as the PHO's care management arm. While the name may be confusing (for individuals who confuse the function with the department), CMG provides the resources and expertise for the PHO to pursue care management initiatives. The purpose of this section of the Reference Notebook is to educate our physician membership on the overall structure, function and resources of CMG.

Organizationally, CMG is a department of Spectrum Health and as such, is fully funded by the system. As the care management arm of the PHO, WMPN has access to resources and staffing devoted solely to improving the quality and efficiency of the care delivered through the PHO. The simplest description of the WMPN-CMG relationship may be to compare it to a provider - client relationship. WMPN currently functions as one of several CMG clients (CMG provides services throughout Spectrum Health). However, as a client, CMG provides WMPN with dedicated resources/staff to pursue the organization's identified care management initiatives.

CMG's current initiatives/committees are outlined below:

Medical Practice Committee - Chaired by Phil Henderson, MD, the Medical Practice Committee (MPC) is a working committee of the PHO which includes all risk group medical directors as well as several specialist representatives. The purpose of this committee is to manage progress and direct specific care management efforts.

Data Analysis Subgroup - A sub-committee of the Medical Practice Committee that is working on Priority Health reports in order to allow individual primary care physicians (PCPs) to compare themselves with other physicians within their specialty. In addition, the group has begun to identify high cost patients and high cost disease and service categories which ultimately will assist the group in identifying targets for improvement.

Pathways or Guidelines Subgroup - A sub-committee of the Medical Practice Committee, this group works on the development of clinical pathways and guideline development.

Care Facilitation Subgroup - Historically called case management, this area has primarily consisted of non-physician, skilled professionals coordinating the following functions:

- Coordinate the time consuming work involved in connecting patients with services in a high quality, cost effective manner;

- Coordinating/managing referrals to other services; and

- Discharge planning when patients are in the hospital.

Please refer to the chart below for a general overview of PHO committees and their respective relationship to CMG.