Transcript INTRODUCTION CASE MANAGERS AS GOVERNMENT ANACONDAS 11/7/2015 No place to hide Buti! Please release our money for DoH!!!!!!!!! Background of the project (including problem) • Problems encountered before the implementation of.

INTRODUCTION
CASE
MANAGERS
AS
GOVERNMENT
ANACONDAS
11/7/2015
No place to hide Buti! Please
release our money for
DoH!!!!!!!!!
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Background of the project (including problem)
• Problems encountered before the
implementation of the initiative
• The current revenue management practices then
did not meet compliance expectations and these
were challenges in areas of Patients registration,
administration, ICT systems, Billing Procedures
and systems that ultimately compromised the
effectiveness and efficiency with which revenuerelated operation was executed. The audit
findings were as follows:
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Root cause: Revenue collection
Knowledge deficit
• Relating to classification, processes and procedures of
patients enrolled on medical aid after funds have been
depleted or exhausted from the Private Sector/clinics
patients are then transferred to the Public hospitals and
classified as HI – and charged R40 per 30 days H2 paying
R45 per 30 days) instead of being classified as Private
medical aid patients and be charged as per Uniform Patient
Fee Schedule tariffs and according to level of care that
means: ICU-Intensive care unit-patients are charged R3060
for every twelve hours,Highcare-R1232 every twelve
hours and General ward –R851 per day.
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ROOT CAUSE
• Foreign Policy-Incorrect patient classification of private foreigners without
proper documentation led to depletion of financial resources, tracing
impossible since they move from one place to another/ or province to
province even to informal settlement, the outcome write offs debts.
Measures
• The Department of Revenue and Budget Administration was faced with a
huge over-expenditure on voted budget which necessitated a mind shift
towards and more aggressive and strategic approach to generate revenue
• Inaccurate capturing of pertinent data and ICD 10 Coding on the PAAB
system especially patient enrolled on medical aid led to rejection of claims
or stale accounts submitted for settlement to the Fund
• Gauteng Department of Health in line with the National Department of
Health established case management services at public hospitals to
facilitate, communication and coordination of services between the
service provider, and funders to promote quality, safe and cost effective
health outcomes for the individual patient
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Creative/innovative ideas
• Case managers at Tembisa Hospital laid down
a foundation for case management and
independently developed Vision, Mission
Statement, Protocols in line with the National
Core Standard M16 Assessment Tool,
Procedure Manual Medical Scheme Act 38 of
1998 etc.
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STRATEGY IMPLEMENTATION
PULL AND PUSH STRATEGY (Marketing Strategy)
• Aggressively promoting the concept of Case
Management, PMB (Prescribed Minimum Benefit) and
building a reputation with customers.
• Administration and ward clerks, nursing staff, Executive
Management and the CEO as the accounting Officer to
buy-in and promote the new innovation and add value
to the organization
TOOLS USED
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Uniform Patient Fee Schedule Tariff guide
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Charge sheet
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Prescribed Minimum Benefit
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Training and development of staff
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Mentoring and one-on-one interviews
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STRATEGY IMPLEMENTATION
REVENUE COST DRIVERS
• Initiative was to identify systems which will augment and
generate revenue (These are externally funded patients)
are charged as private patients at a low premium using
Uniform Patient Fee Schedule Tariffs rates guides.
• South African Police –prisoners awaiting trial must be
accompanied by a Police with Authorisation form SAP70
• Private Correctional Services –prisoners serving time must
be accompanied by a Prison Warder with Authorisation
form G111
• Road Accident Fund-patients involved in Motor Vehicle
Accident-History taken by an ambulance driver/driver of
the car or witnesses, incident form completed by the clerk
at casualty if the patient is treated and discharged then
,RAF1 is completed by the Doctor, for all in–patient RAF2 is
completed by billing department clerks
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STRATEGY IMPLEMENTATION
REVENUE COST DRIVERS
• INJURYY ON DUTY (WCA)-employer must sign the report,
commissioners registered name with compensation
commissioner, and business registered number, employer
contact numbers, area where business is situated and type.
• W.CI.2-EMPLOYERS REPORINJURT
• FIRST MEDICAL REPORT W.CI.4
• FINAL MEDICAL REPORT W.CI.5
• Private Medical Aid patients-patients enrolled /ensured on
medical aid and whose funds are exhausted or depleted
from private clinics are then transferred to public hospitals
and classified as private patients and benefit from PMB.
• The procedure is to contact the Fund/Medical aid company
• Enquire if the member is active / availability of funds,
provide primary and secondary ICD 10 codes, ask for
Authorisation number
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Domain 3: Clinical Efficiency
Management Systems ensure patients
receive adequate, safe, quality health
care.
PURPOSE
• To determine whether the ongoing services are reasonable,
medically necessary, and covered by the benefits
• To establish processes, procedures and protocols to manage
financial risks for payment of care, protect and mitigate against
unnecessary cost being imposed on patients
(Advise customers to apply for Exgratia)
• Procedure to monitor and mitigate against medical aid funds being
exhausted and them not having access to care
• Ensure billing and case management systems are not under/over
charged patients.
• To reduce claims rejections and stale accounts
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PURPOSE
• The inflow of cash was excellent but the escalation of
health care costs impacted negatively on budget because of
overcrowding and extended average length of hospital stay
led to increase per day equivalent cost estimated as R1995
per day as a norm for Tertiary Hospitals.
• To control cost we came up with innovative ideas to create
awareness in Community Empowerment within case
management.
• Case managers conduct daily ward rounds to identify
patients needs in line with the Six Quality Priorities based
on National Core standard as set out by the National
Department of Health and developed different ways to
offload and reduce cost.
• Case Mangers went to the wards during visiting times, Out
Patients clinics morning and afternoon to raise awareness
as a means of alternative hospitalization
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TARGET AUDIENCE
• Chronically ill patients (Senior Citizens) not on proactive treatment
diagnosed as having stroke and terminally ill patients diagnosed as
having cancer, these patients need not be admitted to Tertiary hospital
but may be referred to alternative means of hospitalization
• To promote smooth transition of care during patient discharge or transfers
to other settings i.e. step down facilities, Home based care ,
Rehabilitation / Palliative or /Hospice centres which are 24/7 with doctor
and nurses on duty for constant nursing interventions like observations,
position changing to avoid bedsores, feeding and daily full wash.
• Goal of health talk/education
• Adjust to living as independently and safety as possible
• To reduce cyclical patterns of short-term readmission to acute facility thus
reduce cost.
• To reduce chances of patients developing nosocomial infections
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INNOVATION
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Community Empowerment reduced average length
of stay from 27.8 days to 10 days e.g. (HIV/AIDS/TB)
thus saved cost
Measuring effectiveness base on changes and
awareness after campaigning for PMB, Case
Management and Community Empowerment
showed positive impact and excellent patient’s
outcomes namely: compliance to treatment
reduced complications and cyclical patterns of
short-term readmission to acute facility
Preferences : there is a Paradigm shift, customers
/patients enrolled on medical aid are now
consulting at Tembisa Hospital outpatients/family
medicine which is 24/7 with doctor and nurses on
duty and had become the “thee’ Designated Service
Provider (DSP network)
The Survey conducted showed that perception and
staff attitude was modified
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Benchmarking
Tembisa Provincial Tertiary Hospital is known as
the centre for Benchmarking on Case
management for the whole of Gauteng
Province, even Cross Border namely: St.Ritas
Regional Hospital in Limpopo ensuring that the
concept of case management and M16 National
Quality Assurance Assessment Tool is known,
practiced, acknowledged and understood in the
Public Sector
Revenue collection
Collaboration with Billing displayed efficiency in
Revenue generation and collection ensuring that
expectations and targets are met e.g. target set
for Tembisa 2013/2014 was R18, 000,000
Revenue collected by the end of 31 March 2014
financial year: R19, 127,057
Over collected by R1, 127,000 which was
beyond our expectation
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INNOVATION
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Competitive Edge: Case Management project created a
competitive edge amongst staff and stimulated internal
motivation for staff to enter for different competitions
to improve quality performance and raised a bar and
efficiency in the standard of nursing care. These are the
different awards won by the unit:
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CMASA national awards at Sun Hotel OR Tambo May
2015-won 2 trophies for a Team and the Best case
manager of the year in the public sector
CMASA national awards at Cape Town 15th May 2013
(case study)
CMASA national awards at Indaba Hotel 18th April 2012
(case study)
Khanyisa Awards the best in Case Management July
2012
Dinaledi Service Excellence Awards 2013-Face of
Government
Dinaledi Service Excellence Awards 2013-Face of
Government and Best National Core Standards in Case
Management
Khanyisa Awards won first prize in National Core
standards 2014
Central Public Service Innovation Award-First Prize 31
/10/2014 awarded a gold/silver plated trophy and a
R10,000 from sponsor DATA CENTRICS.
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SUSTAINABILITY
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Top-down management support from the CEO to the Executive management level to strengthen and
motivate staff to attain set objectives for the organization
Invest in on-going training and development of staff / health talk / education to patients and their families
for excellent outcomes
Marketing strategy: Strategy Implementation-Pull and Push Strategy as a long term
Attend seminars, workshops and conferences to enhance the skill in case management
Private Public Partnership –Medikredit/GEMS/Alexandra Forbes consulted for in-service lecture for
Tembisa Administration clerks /Case Managers to enhance the skill on capturing of pertinent data
Involve /engage different Embassies in South Africa to pay for health services delivery for their patients to
recover hospital debt rather than writing off debts
Auditing of records/file Participate in self assessment and monthly meetings for Quality Assurance
Committee to identify service delivery gaps
Community work based projects should be on-going
REPLICABILITY
Benchmarking
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Tembisa Hospital is known as the centre for Benchmarking on case management for the whole of Gauteng
Province also Cross Border Province-St.Ritas Limpopo Province
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Promotes learning and exchange of knowledge and expertise on innovation in the Public Sector
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National Core Standard: Assessment Tool M16 on Functional Risk Areas evaluation at Gauteng Hospital
excelled in ratings from 85.5-100%.
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Revenue generation improved in most of Gauteng Provincial and Regional Hospital as per Medikredit
report
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Referral Systems to alternative hospitalization improved patient’s lives and increase in life expectancy
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CEO Dr Pekane introduced, coordinated and facilitated a meeting between Tembisa Tertiary Provincial
hospital and Ekurhuleni District Management to reduce overcrowding and cyclical readmissions of patients
to hospital with excellent outcome.
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CHALLENGES
Knowledge deficit
• On case management concept and computer literacy to nursing staff
• Members /Customer not having knowledge on their fund benefits –medical aids
• Incorrect classification of patients and application of Foreign Policy for foreigners in South Africa
• Prescribed Minimum Benefit: lack of knowledge and procedures to access benefits funds from the
Funders for patients enrolled on medical aid to generates revenue
NON-DISCLOSURE
• Patients enrolled on medical aid do not disclose in time, hide cards and disclose on discharge in
need of fit for duty letters or when they sign Refusal Hospital Treatment to be admitted at private
clinics
Shortage of resources for example:
• individual computers in each department for nursing staff and ward clerks.
Overcrowding and non traceable of foreigners
• Tembisa community has grown up to Midrand/ Diepsloot. Daily consultations at Out-patient =2000
and average admissions per day 700.
• The community and foreigners sabotage the referral system and patients cannot be turned back to
the clinics once inside the hospital.
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Perception and staff attitude was the main obstacle due to resistant to change, now modified
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LESSONS LEARNT
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We have to adapt to the new modern trends of doing things.
Every one everywhere needs technology to be able to position our organisation in the competitive market
and win the hearts of our customers
We have to admit to customer service failure and act immediately
Customer is always right until proven wrong,
We have to strive to satisfy customer needs and wants for the value of money and add value to our
organization
Many services need to guide customers through safety through the service encounter and contribute to
the Millennium Gauteng Strategy
Teams: Collaborate ideas across spectrum thus create synergy and add value to our organisations in South
Africa.
Measure results in efficiency performances supported by quantifiable indicators and questionnaires.
Embark on qualitative and quantitative survey to identify service delivery gaps.
Talking of top-down management support!, The Minister of Public Service Mr. Chabane Collins left a
legacy for Tembisa Hospital and DoH. He became the first Minister to position South African Public Sector
Case Management in the Global competitive market.
(CHANTING-LETS ALL STAND AND RESPECT OUR LEADER)
Long live Mr Chabane Long Live!
Long live Mr Chabane Long Live!
Long live Mr Chabane Long Live!
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OUTCOME OF THE PROJECT –(VIDEO)
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