Complex Care Requires Unique Solutions, Real Vendor Commitment
Unfortunately for payers and patients, that "reality gap" can upset the critical balance between delivering the most cost-effective, yet best possible medical care for a patient, according to Jack Stahley, Vice President, Complex Care Sales at MSC Care Management (MSC), a One Call Care Management company. On the other hand, with the right experience, tools and dedication, Stahley said it can be done.
"The value of complex care is in having both a unique approach to these claims as well as making the investment to turn that unique, innovative model into a reality," Stahley said. "Many complex care providers talk about elevated care, but they don't really 'put their money where their mouth is,' as the saying goes."
Stahley explained that MSC has invested heavily over the years in both clinical expertise and technology to optimize quality of care for the patient, identify and improve efficiencies, reduce administrative burden and control costs for clients. As far as clinical and technological resources go, Stahley said, MSC is the market leader.
MSC offers all of the following in-house, which is very rare in this market segment: Assistive Technology Professionals; a home modification team; vehicle modification experts; rehab and custom mobility experts; 24/7 nurses; a certified Legal Nurse Consultant and regional clinical specialists.
"Claims adjustors are trying to minimize risk while, at the same time, trying to ensure patients are getting the most appropriate care," he said. "Driven to support that delicate balancing act, we have assembled the most professional, experienced team of people in the field. Many of whom are registered nurses, with a history of catastrophic and/or complex case management expertise, recognizing the delicate balance between coordinating services and delivering cost savings to customers."
One example is MSC's ability to deploy on-site, clinical resources to facilitate the discharge planning needs of the injured worker with the rehab facility staff. The key, according to Stahley, is staying ahead of the discharge curve by anticipating immediate critical care needs and having the processes and services in place to ensure a safe and secure transition home, said Stahley.
Kevin Glennon, Vice President, Home Health and Complex Care services at MSC cited the company's clinical quality assurance (QA) program as another example of not only talking the talk, but also walking the walk. Every file gets a weekly, in-depth examination not only by on-staff nurses, but also by MSC's QA team searching for certain red flags. For example, they will look for a wound showing delayed healing which poses a potential risk of infection, and if left untreated, possibly needing surgical intervention.
"The idea is to prevent untoward events as the person progresses through the recovery process," Glennon said, adding that MSC Complex Care professionals offer a thorough understanding of the multifaceted needs and the devastating impact a catastrophic injury can have on the individual's quality of life.
At the heart of MSC's complex care initiatives are the comprehensive review and prompt reporting of treatment plan goals, interventions, progress and outcomes. The company provides a cross-functional, holistic approach that aims to lower claim costs and provide superior care for the most complex and catastrophic cases.
It is usually a small detail that can result in big results. Recently, Glennon worked on a file, involving a police officer injured in the line of duty that left him paralyzed below the waist. The officer had successfully returned to work in the dispatch unit; however, wound care services remained in place for an area that just wouldn't heal. The MSC team completed a comprehensive assessment, including pressure mapping and the results revealed some irregularities located at the back of his custom wheelchair. This was causing increased pressure on the skin just above the buttocks, which was preventing the wounds from healing. With some minor repairs to the back of the wheelchair, the underlying cause was eliminated and the wounds completely healed over the next few weeks.
"It was a minor fix but a major win for both payer and patient, with significant cost savings," Glennon said. "It often comes down to not just asking the right questions, but also digging a little bit deeper to uncover the actual cause."
When the MSC complex care team is engaged from the beginning of a claim, it can assist in planning a care path that further ensures the cost/care balancing act is done right. Through MSC's Early Referral Notification (ERN) program, early intervention provides greater control, fewer mistakes and better overall care management. Things like home and vehicle modifications, air or ground transportation services and even hotel accommodations can all be coordinated and in place early in the recovery phase, alleviating additional family burden and allowing them to focus on their loved one and their recovery.
"We are way beyond just being a call center taking orders," Stahley concluded. "We take a big picture, clinical view of each case, anticipate needs and make appropriate recommendations that provide solutions for our clients and their injured workers. We deliver complex care the right way because we offer both a unique approach and have the resources in place to do it."
(The above piece is part of our continuing Insights series designed to highlight key products and services to our readers. This paid-for Insights was written and edited by Risk & Insurance®
on behalf of our marketing partner. Additional Insights can be found on our Web site at www.riskandinsurance.com.)
April 3, 2013
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