JLN Process - Manage costs of catastrophic cases

Process Group

Care Management

Objective

Reduce costs of managing catastrophic cases

Input

• Diagnosis

• Treatment plan (including all current therapies including pharmaceutical therapies)

• Eligibility

• Demographics

• Geography (address for beneficiary)

• Provider list

• Rules

Output

• Treatment needs assessment

• Treatment plan or clinical pathway

• Clinical recommendations to attending physicians

• Care management

• Case identifier

• List of beneficiaries with catastrophic management needs

• Provider list

• Assignment of case worker

• Assignment of restrictive benefits plan

Task Set

• Identify cases whose liability will exceed cost threshold

• Monitor these cases and assess treatment plans to see if there are ways to reduce costs

• Communicate with clinicians at the hospital to suggest a cost-effective treatment plan

Measurable Outcomes

• catastrophic case cost are reduced