J-22 Case Management.pdf

CASE MANAGEMENT SERVICES

A. Case Management Overview

This process is a collaborative effort between the responders, their healthcare providers and the case manager. Case Managers will normally be a Registered Nurse or a Licensed Practical Nurse. The case manager will optimize communication between the providers and the responder as well as obtain and review medical records, ascertain medical history, diagnoses and treatment plans. Case Managers will address the unique healthcare needs of the responder. The case manager will provide comprehensive assessment, coordinated review, planning and monitoring of the responders case and enhance communication. This process will resolve complex issues to optimize quality, promote efficiency and maximize cost effectiveness.

Below outlines the case management acuity levels.

B. Acuity Levels Acuity levels are reviewed and reassigned as appropriate using an acuity tracking scoring tool.

Level 1/Low Acuity

• Covered diagnosis/referral from one of the following body systems:

o Mental Health o Aerodigestive o Upper or lower airway o Musculoskeletal

• Questions regarding treatment, prescription benefits

• In treatment

• Questions regarding program benefits

Review case at least quarterly (every 90 days)

Level 2/Moderate Acuity

• Covered diagnosis/referral from 2 or more body systems

• Hospitalization for WTC-covered condition within past 180 days

• Emergent referral within last 180 days

• Language barrier

• Responder requiring frequent/multiple referrals/prior authorizations for treatment

• Complex medications

• Repetitive unauthorized use of WTC ID card

• Coverage/claim issues

• Change in physical or psychological status

• New to program/recently relocated, needing new providers

• May also include descriptors from lower acuity level(s)

Review case at least once per month (every 30 days)

Level 3/Intense Acuity

• Covered diagnosis/referral from 2 or more body systems

• May also include descriptors from lower acuity level(s)

• Hospitalization for WTC-covered condition within last 120 days

• Emergent referral within last 120 days

• Threatening behavior (responder threatens to contact media, political figure, attorney, etc)

• Verbally abusive

• Unusually time-consuming *

• Accumulating exceedingly high coverage expenses

• Coverage review in progress

• New to program with multiple needs o High emotional or financial needs

Review case at least weekly (every 7 days)

* Frequent calling; frequent, complex questions, increased need for treatment follow-up

C. Watch List Responders

The Watch List includes responders who have current issues such as a medical review request, complaints about quality of health care services, a tendency to engage media outlets, or are at Case Management Acuity Level 3. The purpose of the Watch List is to provide a compact resource that summarizes special needs of a responder. Typically, these responders require a swift resolution to their issue(s) which are tracked, and shared with NIOSH on a routine basis.