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New Publications Contains Policies, Procedures and Tools to Better Manage Post-Acute Care and Other Extended Care Services

Posted on: Wednesday, 23 January 2008, 12:01 CST

Research and Markets (http://www.researchandmarkets.com/reports/c80341) has announced the addition of "Managing Post-Acute Care and Other Extended Care Services (Updated 2008)" to their offering.

Policies, procedures and tools to 1) improve efficiency and quality while controlling the cost of care in any skilled facility or rehabilitation service, as well as home care, and 2) provide methods and criteria to objectively transition patients across the continuum of care from acute to subacute or inpatient rehabilitation, skilled outpatient/nursing facility care, hospice and, when applicable, custodial care services. Review criteria/benefit 'interps'. Stroke and cardiac rehabilitation policies. Numerous forms and Medicare coverage information, Medicare average LOS by DRG, 2006 data. Extensive references. These tools and strategies are survival tactics for managed care contracts and prospective payment systems.

Preface

The focus of this manual is entirely related to the management of the care of health plan members who require extended care services for the management of a condition in a contracted and authorized location for a defined period of time as a common Medicare risk health plan covered benefit. Medicare benefit determinations are the 'gold standard' for these determinations. Many health plans offer additional benefits in the Certificates of Coverage, either as a marketing tool at no additional cost to the member or at an added premium.

Therefore, all policies, procedures, benefit interpretations and the like throughout this manual need to be carefully reviewed for applicability to the population served by each managed care organization (MCO), whether a health plan, PSO, a capitated medical group, a MSO, PHO or another managed care entity.

This manual has been compiled in recognition of the need for objective guidelines, policies and procedures for the management of post-acute transitional care inpatient, skilled nursing facility and rehabilitation hospital as well as outpatient integrated rehabilitation medicine programs providing physical, occupational and speech therapy. Standards for the review of requests for services are an integral part of the management of these services. The observations are based on the experience of many Health Maintenance Organizations, capitated multi-specialty medical groups, behavioral health care providers and the literature. Specific standards for the review of occupational, physical and speech therapy can be found in Apollo's Managed PT/OT and Rehabilitation Care Manual.

This manual provides a model for common, acceptable, customary, reasonable and necessary managed care contract benefit interpretations and objective evidence-based review for the management and authorization (or denial) of services. Each must be reviewed by physician and other members of the medical policy committee of the health plan or contracted/delegated medical group and modified and adapted as appropriate to the circumstances of care in their community and as provided in their contracts.

Quality care is cost effective care -- cost and cost-effectiveness may be quite different. Cost effective health care is necessarily quality driven (true quality, that is; not excessive care under the guise of 'quality'). Attention must always be focused on the issues that will result in optimal medical/surgical outcomes in the specific local medical environment. No item is more costly than the treatment of an avoidable complication, whether secondary to a treatment or procedure or due to the lack of adequate care (commission vs. omission).

'Right time, right place, right reason and right provider' has been used as a definition of appropriate, quality-based necessary care. Low-technology (and usually cost) interventions are not necessarily cost effective, and high-technology interventions are not necessarily cost ineffective. Applying the most appropriate, timely and needed clinical interventions for prevention, diagnosis, and treatment ('do it right the first time') is a critical key to the most cost-effective care. For example, the use of coronary artery bypass surgery instead of medication for patients with left main coronary artery disease results in a cost-effectiveness ratio of about $2300 to $5600 per year of life saved. At the other end of the spectrum, use of this surgery for other patients with less critical coronary artery disease does not deliver a savings or equivalent 'bang for the buck'. Refer to Deyo, R. A.: Cost-effectiveness of primary care. J of the Am Board of Family Practice (13) #1:47-54, 2000 and other cost-effective care references in the References and Resources section near the end of this manual.

The proactive delivery of audited high quality preventive health care services will reduce costs for a given population or community of patients over time. A recent example relating to Merrill Lynch employees and retirees was published in the Wall Street Journal on May 23, 2000.

For more information visit http://www.researchandmarkets.com/reports/c80341

Source: Business Wire

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