There are two components to Phase 1, the Care Management Opportunities Assessment and the Operations Assessment. This comprehensive assessment serves as the basis for the next phase, the development of a comprehensive care management strategy.
Opportunities Assessment
As a result of this assessment process, CAI subject matter experts provide an opportunities analysis that facilitates a hospital's understanding of past as well as current utilization patterns and is used to set the appropriate direction for future care management programs.
This analysis consists of standard set of hospital reports based on facility inpatient utilization, case management alternate level of care data as well as provider and insurer specific utilization data. This provides a "broad brush" picture of the hospital's utilization, case management and discharge planning opportunities.
The objectives of this analysis are:
- To identify areas of opportunity for improvement in terms of utilization and cost
- To determine the appropriate size, scope and focus of a hospital's care management program
- To suggest resource reallocation among the various care management program segments to optimize return on investment on their care management expense
The following describes the most common types of analyses, compared to industry standard measurements:
- Total dollars spent by major bill/claim categories and subcategories
- Length of stay (LOS) by diagnosis
- One and two day LOS
- Denial/ diversion rates by insurer
- Overturned decisions on appeals
- Alternate level of care data
- Insurer contract arrangements
Operations Assessment
The care management operations assessment is the second component of Phase 1, and consists of the following four key areas of focus:
Program Scope and Design
During this assessment, we review the current scope of the care management program with respect to meeting the hospital's objectives. Specific steps include:
- A review of the results achieved to date as well as the design and focus of the
program,
- Evaluation of staff adequacy and allocation of resources, and;
- Review of the adequacy of clinical support underlying the programs with a focus on the criteria in place, staff application of criteria and guidelines, and physician review mechanisms and
processes.
Process, Policy and Procedures
We review all current care management processes, policies and procedures for identification of any barriers to efficiency, productivity and results. This is based on a review of hospital documents, as well as the conduct of a hands-on review of current operational procedures and workflows,
against best practices. Elements of specific interest include the case review process and the quality of case-related documentation.
Staff Performance and The Identification Of Training Needs
This aspect of our assessment includes an evaluation of care management skills/capabilities
of the hospital's nurse reviewers, case manager, and medical director/physician reviewer staff. The results of this assessment
can be used to develop a prescriptive learning plan to enhance the performance of both nursing and medical staff.
Care Management Information Systems Evaluation
The capability of the care management systems to support current and future care management programs is a critical issue for many hospitals. Systems that support productivity, case documentation and operations management are essential to success. CAI reviews current system infrastructure and applications to support utilization and case management programs, appropriate claims submission and billing procedures. CAI will make recommendations regarding the required functionality necessary to achieve enhanced near and future term care management programs.
Data Management Capability Assessment and Data Analysis
As part of the assessment process, CAI reviews the hospital's data management capacity in terms of the ability to prepare and analyze utilization information for the purposes of focusing
on care management resources and optimizing reimbursement.
Provider Network Relations
CAI evaluates the current state of the hospital's relationships with its medical staff relative to their cooperation and compliance with
recommendations made by the care management staff. CAI also reviews the availability of and accessibility to alternate settings of patient care. | 
