Noetscher, Cheryl M. MS, RN
In the first article in this collection, it was suggested that health care data should be more than an end unto itself, that the human element-the use of this resource for the improvement of the condition of the patient-should be the aim of data collection and analysis. Health care professionals believe that data should be useful to managers and clinicians, especially as it relates to daily work with staff and patients. This article outlines methods for using health care data in daily interactions among providers, payers, and patients especially with respect to case management.
In the previous articles, data have been discussed as "stand alone" information. Much of the data are procured or analyzed retrospectively, after a patient has completed at least one episode of hospitalization. Such information might be based on an individual's membership in a particular demographic group, such as an age level, gender status, or diagnosis. At the same time, there is also a need to obtain and utilize data in the concurrent management of a patient's care or the ongoing management of a department or service line. Sometimes this concurrent information is readily available; frequently, however, there is no way to obtain the data in time to benefit the situation.
Comments about outcomes in the previous articles have indicated that the health care field is still grappling with measurement of meaningful data that will show the effectiveness of care. Many times the systems are not in place to generate the data needed. Still, health care professionals are beginning to understand the need and usefulness of this data in the quest to improve the human condition.
CASE MANAGEMENT AND HEALTH CARE
When a person enters the health care system as a patient/client, the experience is similar to taking a trip to a foreign country. When traveling, a person meets many new people; is usually expected to follow a different time schedule from his or her normal routine; eats different food; sees, hears, and experiences new situations; and may try to communicate in another language. Money exchange, transportation, and other unfamiliar or unknown circumstances may cause stress for the traveler.
To have some information about what lies ahead, to assist in planning, and to make sure the trip runs smoothly, many travelers will use a travel agent or tour guide. This person makes travel and accommodation arrangements ahead of time; helps the traveler adjust to cultural changes; may interpret language, local customs, or situations; and educates the traveler about expectations as the trip progresses. The tour guide alleviates stress for the traveler by smoothing out and managing difficult or unfamiliar situations.
In order to provide maximum assistance, the tour guide will obtain information from the traveler ahead of time. The traveler might raise questions about where the trip is to take place, modes of transportation, traveling companions, sights of interest, and funds necessary. All this takes place before the trip begins. These activities generate the information the travel agent needs to plan. Frequently, the agent will use geographic data, weather information, and prior experience.
Similarly, patients/clients traveling through the health care system will navigate more smoothly if they have access to a "tour guide." After all, they will be meeting many new people (providers, caregivers); they will be expected to follow a time schedule encompassing diagnostic tests, surgery, rehabilitation, and other services; they will be following a different diet (or maybe not eating at all); and they will be trying to understand and communicate in the language of "medicalese" (for example, NPO, PPO, MRI, CVA, SNF, to name just a few). Because of their medical situation, these travelers may find that their whole lifestyles have changed. They may feel stranded and alone in this foreign land.
Like the tour guide for the traveler, the tour guide for the patient alleviates stress by providing information (data) to educate and smooth out or manage the unfamiliar. In many different health care settings-the hospital, home care, rehabilitation, or office-this tour guide is the health care case manager.
One definition characterizes case management as "a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual's health needs through communication and available resources to promote quality cost effective outcomes." 1
The concept of case management has been in existence for many years. Although practiced by a number of different groups (nurses, social workers, psychologists, and others) in a number of different ways, the basic concept remains. Recently, case management has assumed greater importance in the context of efforts to coordinate care or services provided in a timely, cost-effective manner. There has been much discussion about which services should be provided, what kind of care rendered, who should provide the care, and when it should be given. In this environment, patient outcomes are being emphasized.
The definition and functions of the case manager will inevitably change depending on the service population and whether the case manager is employed by a provider, a payer, or directly by the patient. In some case management models, direct physical care is provided. 2 In others, coordination of services across the continuum of care is emphasized. The emphasis of the health care paradigm has changed from a retrospective episode focusing on intervention to make the patient well to one of wellness, prevention, and education. This means continuous care and monitoring for populations or groups (e.g., cardiac patients, the frail elderly, women and children).
The current practice of case management has developed as a clinical process that includes accountability for coordinating care and services over time, sometimes through various locations and various levels of health. Major functions of the health care case manager include:
* support for clinical, quality, and financial outcomes
* negotiation and coordination of services and resources
* intervention and resolution of issues that may have a negative quality-cost impact
* creation of opportunities and systems to improve outcomes 3
CASE MANAGEMENT AND HEALTH CARE DATA
The need for data has changed as the health care paradigm has changed. Historically, utilization review was a useful process when reimbursement was mainly retrospective. Providers had the luxury of having a few days to decide whether or not the patient belonged in an acute care facility. Lengths of stay were longer as well. Little emphasis was placed on efficiently planning diagnostic testing or medical regimens. The focus was on the individual episode of illness. Variables such as length of stay, mortality rates, and cost per case were being measured, but because data were looked at retrospectively, they really were not used by those managers and clinicians caring for the patient.
With the impetus provided by managed care and tighter government regulation, appropriate utilization of resources became an important objective. Greater emphasis was placed on the use of quantitative data in case management. This caused case managers to ask more questions: How many chest x-rays were done? How many complete blood counts (CBCs) were appropriate? Did the stroke patient really need a magnetic resonance imaging (MRI) and a computed tomography (CT) scan? Standards developed for how much or what type of care was needed, dependent on diagnosis, as the concept of utilization management emerged. Clinical pathways were assembled to encourage practitioners to follow a more consistent pattern of practice, decreasing the wide variation in practice that was evident in the treatment of patients with the same diagnosis.
In this environment, a recognition developed that even when patients were admitted with the same diagnosis, there were wide fluctuations in the treatment ordered. For example, one physician admitting a patient with community-acquired pneumonia might order seven days of intravenous (IV) antibiotic therapy, a CBC every day of the hospital stay, and chest x-rays on the day of admission and day three. The patient might have an eight-day stay, returning home after being on oral antibiotics for 24 hours, with continuing antibiotic therapy after discharge. A second physician admitting a patient with community-acquired pneumonia might order a three-day course of IV antibiotics and a CBC and chest x-ray on admission. If a second CBC on day three showed improvement, and if the patient was afebrile and taking fluids, oral antibiotics would be started and the patient might be discharged on day four.
Obviously, from a resource utilization and reimbursement standpoint the second scenario would be preferred. But which course of treatment provides a better outcome for the patient? How do providers know that shorter lengths of stay won't result in readmissions? These issues can be addressed only through the development of health care data and analysis. Such data can identify alternative courses of action and support the selection of the best approach.
To decrease the wide practice variation and to encourage best practice, critical pathways (clinical paths, Care Maps, and related tools) were developed. Based on professional guidelines and current research, these mechanisms challenged the idea that longer stays were always better for the patient and always provided better care. They also provided guidance to physicians who might admit only one or two patients per year with a particular diagnosis, and to nurses who might not regularly care for a particular patient type. In these circumstances, health care data provided clear definition of outcomes and resource indicators. This resulted in quantification of variances as a basis for improvement of practice patterns.
As utilization management gave way to case management in acute care facilities, it became the case manager's function to follow patients on a clinical pathway. If a patient did not follow the plan as stated in the pathway, the case manager might ask the physician about a change in management. This was often met with resistance, especially by physicians who regarded pathways as cookbook medicine. In most instances, there was no way to prove that the pathway provided better patient outcomes than an alternative care regimen. As a result, case managers and other clinicians were not always successful in persuading physicians (and others) to adopt clinical pathways. In many cases, these difficulties suggested the need for more refined utilization and outcomes data to support changes in practice.
Patients following a clinical pathway need some oversight, but those not following a pathway are the ones requiring clinical management. In addition, because case management encompasses the care continuum, it was recognized that data needs also are present beyond the acute care episode.
Outcomes data used in the case management process are usually considered in three main areas: clinical outcomes, cost efficiency/utilization outcomes, and customer satisfaction/quality outcomes. Clinical outcomes data relate to changes in the condition of the patient; cost efficiency and utilization outcomes pertain to resource use; and customer satisfaction and quality outcomes are customer (e.g., patient, provider) concerns, and attitudes.
Developments discussed in this article relate to the principles of data use: clarity of data sources, data validity and consistency, data relevancy, and data accessibility, as well as the human imperative. For example, while it is tempting for case managers to focus on internal data, or to develop their own functional assessment tools, it is important to recognize that proper selection of data sources be made so reliability and validity will not be compromised.
Consistency of data elements must be maintained because this will affect the ability to analyze, draw conclusions, and benchmark against standard data sets. It is also tempting to change what's being measured halfway through the study, especially if things are not turning out as expected.
It must be emphasized that the human element is essential with respect to case management. The case manager will be using data applied to individual patient situations, but these data will come from an aggregate population (e.g., patients who have had a Caesarean section or a total hip replacement).
The case management process involves identification of cases and assessment, care planning, implementation, evaluation, ongoing monitoring, and reassessment. 1,4 Data considerations relate to each part of this process.
IDENTIFICATION OF CASES AND ASSESSMENT
In many organizations, case managers constitute a very limited resource. Traditional case management has relied on a referral system among providers, especially when a social worker or nurse was utilized as a primary discharge planner. A social work or case management consult usually was ordered when it was recognized that a particular patient might require equipment or services after discharge. What triggered this kind of referral? Often based on experience with a particular patient or type or age group, the provider would instinctively know that a patient would not be successful in maintaining health without some outpatient assistance.
When case managers started following particular patient types or patients on a clinical pathway, new problems emerged. What do we do with patients who fall off the pathway? Furthermore, there were often many patients with a particular diagnosis (e.g., pneumonia) scattered throughout units, causing a case-specific case manager to work with a heavy patient load in several areas.
A fundamental question then arose: What patient populations should be followed by the case manager? Should a respiratory case manager follow every pneumonia or chronic obstructive pulmonary disease (COPD) patient? Usually this isn't possible because there are not enough case managers to follow an entire population, or because inpatient admission diagnoses may not be specific.
Although referrals and case-specific management should not be abandoned, data can help to define which cases deserve the case manager's attention. Working with the information management, finance, and quality improvement departments, decisions are made by each organization. Efforts should be made to focus on populations with the greatest risk of each adverse outcome, such as an extended hospital stay or a readmission. Areas to consider include
* diagnosis-related groups (DRGs) where length of stay (LOS) is longer than targeted benchmark levels
* high volume (large number of cases or procedures)
* services or DRGs for which the organization desires best practice status or wishes to attract increased utilization or admissions
* DRGs where cost per case exceeds reimbursement
* diagnostic categories in which improvements in patient, physician, and staff satisfaction are desired
* problem-prone DRGs involving quality issues
It is important for managers, clinicians, and case managers to communicate why data are being used. Staff should be aware of quality concerns and the organization's strategic targets. Most staff members have only a minimal understanding of the reasons to conserve health care resources or decrease length of stay. They are not aware of utilization costs (e.g., costs of testing, supplies) or requirements of insurer contracts.
As part of its primary nursing orientation, Crouse Hospital in Syracuse, New York, shares information about length of stay, cost per case, reimbursement, and costs of common tests and supplies with staff nurses. In addition, profiles of each unit's highest discharge volume DRGs along with benchmark targets are communicated. This provides staff with some perspective regarding populations being considered for case management and utilization activity.
Initiating any type of case management or utilization program should always start with baseline data collection. This activity builds a population and a set of indicators against which subsequent developments can be evaluated. Careful consideration should be given to the populations and variables that comprise this baseline data set. As time passes, case management staff should compare current experience for major indicators against baseline data and against regional, state, and national information. This approach provides information on progress with respect to previous levels within the organization as well as with respect to the performance of other providers in the health care environment.
Another area to consider in the assessment phase is risk assessment. This process is important to ensure that the case manager will focus on patients who are most in need of their services. It involves identifying which factors will make it more likely that patients will need continuing care. Most risk factor tools take into account social-emotional factors (e.g., living alone, no support system, frequent readmissions), health conditions (e.g., multiple diagnoses, prematurity, chronic or progressing health problems), functional status (e.g., activities of daily living [ADLs] ability, sensory or mental impairment), and educational needs (e.g., high-technology needs, complex medical regimen). 5
When these factors are evaluated on admission, or during preadmission testing and workup for elective patients, the information can be used to focus and expedite the case management process as well as to provide better outcomes for the patient through anticipation of needs and services. Education can also begin at this time to help prevent unnecessary readmissions.
Much risk assessment data currently used has been produced by internal sources. Recently, there has been increased interest in this area in an effort to decrease unnecessary admissions to acute care. 6 Hospitals and payers are monitoring types of admissions. More surgical procedures are being performed routinely in outpatient settings rather than acute settings and many diagnoses are being treated in short-stay (23-hour) areas, thereby saving an inpatient admission. The importance of risk assessment data produced through external sources is increasing. Statewide hospital discharge databases can generate information concerning admissions, surgical procedures, and other indicators for a large number of providers. As these expectations increase, it will be important to monitor how patients fare, and whether short stays will have an effect on readmissions.
PLANNING AND IMPLEMENTATION
During the planning and implementation phase of the case management process, data again provide a backdrop for the work of managers and clinicians.
Based on the assessment, risk factors, and diagnosis, a length of stay can be estimated. This is of value to staff as well as the patient and family as an outcomes target. Some hospitals use consensus-based guidelines such as Milliman & Robertson's guidelines. 7 In recent years, the use of benchmark information based on the actual experience of hospitals and other providers has increased. 8 If clinical pathways have been devised, there will be target discharge dates based on benchmark lengths of stay. Some hospitals use a phased approach: When a patient reaches certain clinical, functional, and educational goals, the individual moves to the next phase; when all outcome goals have been met, the patient is discharged.
Whichever approach is used, the estimated length of stay should be communicated to all caregivers and the patient. As part of the admission process, patients can be asked how long they anticipate being hospitalized. If there is a discrepancy between the estimate and the average for that diagnosis, this is an opportunity for the staff nurse or case manager to discuss with the patient reasons for possible longer or shorter lengths of stay. This approach provides patient and family input to complement that of physicians and hospital staff.
It is extremely important for physicians to understand length of stay and clinical pathway targets. They should actively contribute to direct pathway development. Length of stay data by DRG should be shared with physicians on a regular basis.
Physician department meetings and staff meetings are ideal venues for sharing length of stay and utilization data. For length of stay, several parameters should be considered. For each DRG focus, median and mean lengths of stay should be reported. The median length of stay can be used to track changes in practice patterns. It should decrease as variation in practice decreases and there is a tighter distribution. The length of stay standard deviation provides a more direct indication of the variation in practice patterns. As this variation is reduced, length of stay standard deviations will decline. Average lengths of stay will provide information about outlier cases, since one or two patients with long inpatient stays can increase the mean. Regular lengths of stay monitoring and comparison with benchmark data will help to evaluate how practice variation has changed.
With respect to the principles regarding the use of data discussed previously, the need for emphasis on important indicators and their consistent use is essential. The consistent use of a set of indicators will encourage a focus on important objectives by all members of an organization.
In addition to lengths of stay, utilization and resource consumption should be monitored during implementation and planning. This is important for the hospital and payer. Sometimes at the beginning of a case management program, efforts are made to track all utilization and every variance. Resist the urge! All participants will drown in data and will be frustrated by not being able to remedy each problem.
For each DRG or pathway to be monitored, the organization should select a few important utilization and outcomes data elements. For example, in the patient with community-acquired pneumonia, Crouse Hospital began by tracking the number of chest x-rays, CBCs, sputum cultures and gram stains, days on IV antibiotics, days on oxygen and number of oximetry readings, deaths, and readmissions within 30 days. Over time it was recognized that the start of IV antibiotics and the number of days on therapy were the most important measurements indicating length of stay and clinical improvement. The staff continued to monitor the number of chest x-rays because the hospital exceeded benchmark norms. As physician practice patterns changed, other laboratory and oxygen indicators were dropped because these variables did not really change patient outcomes.
As the case management process evolved, the staff continued to monitor deaths and readmissions as quality indicators. Focused studies were conducted over short time periods to track the specific antibiotics used. These studies were developed when the staff noticed that a newer, more expensive antibiotic was being used rather than the effective but less expensive medications suggested on the pathway. The results of these focused studies were communicated to physician groups through the Chief of Infectious Diseases with good results.
Each pathway or DRG will have different indicators to monitor. As another example, the number of intensive care days was monitored for acute myocardial infarction patients. At one hospital, it was found that this was an indicator of resource consumption and length of stay. It was also determined that diagnostic testing was very extensive in stroke patients; in fact, MRI utilization for the hospital was 50 percent higher than for other local hospitals. It was found that this was due to close proximity of MRI testing and the neurological residents' ordering pattern. In addition, stroke patients may be admitted to a neurology unit or to a medicine unit. It was also noted that those admitted to the neurology unit had a more extensive workup, tended to have a neurology consultant, and usually a shorter length of stay and cost per case than those admitted to the medicine unit.
Variance tracking is another type of data collection when algorithms, guidelines, or pathways are used. Again, when a program is initiated, the tendency is to track every variance. Currently, it seems to be more useful to monitor system-type variances such as inability to perform certain diagnostics over a weekend or holiday or a lack of rehabilitation beds.
The case manager can help staff anticipate and resolve some variances due to medical conditions (prevention of infection, education about health status, and care). As practice variation decreases, practitioner variances will also decrease. If payers or hospitals provide practice information to physicians, these variances will decline more rapidly.
COMMUNICATION OF DATA AND IMPLICATIONS FOR PATIENT CARE
Case managers continually communicate with patients and their families, physicians, and payers, not only during the acute episode but beyond. Like the tour guide, the case manager needs to ensure that correct information is given and that the source is known. This is particularly true when presenting results of data collection related to utilization or trends in length of stay and other indicators to physicians and administrators. Knowledge regarding sources, methods of collection, demographics, and time periods as well as the same information for the benchmarks used will ensure a favorable reception as data are presented. It is also helpful to tailor the amount and subjects to the particular audience involved.
For example, if the case manager is trying to bring about the development of a chest pain observation unit, he or she might want to bring together physicians representing cardiology, internal medicine, family practice, and the emergency department as well as appropriate administrators. Data presented might include the number of chest pain patients or rule out myocardial infarction patients admitted per year. This process should include data produced by a myocardial infarction clinical pathway or the results of tracking how many chest pain patients actually had a myocardial infarction. This data can be compared to the number of patients where a myocardial infarction was ruled out and the patient was treated and discharged. Financial information related to the costs of admitting all patients to the cardiac care unit or the intensive care unit also needs to be obtained. The costs of diagnostic tests utilized by these patients should also be obtained.
Another area frequently overlooked when a patient is admitted as an inpatient is the amount of nursing time and expertise required. Often nursing care is not broken out separately. Current length of stay, number of patients admitted but discharged within 24-48 hours, time to thrombolytic therapy, and angiography or stenting might all be discussed, as well as mortality and readmissions.
While the above data are internal, it will also be necessary to have comparison data from statewide sources. If there are trends related to age, gender, or related medical conditions, this information will also help focus case management efforts in those particular areas.
As an added benefit, an analysis of critical diagnostic testing may prove helpful. At one hospital in Syracuse the original treatment algorithm called for cardiac panels to be completed and repeated at certain intervals. By using a more expensive test measuring troponin levels, the hospital was able to produce results more quickly, assisting the physician to rule out myocardial infarction and enabling the patient to be admitted or discharged appropriately. Just because an organization has a pathway or algorithm in place, it should not remain static. Regular review as well as change brought about by new information or research is always necessary.
In this type of process, hospital data may show that the organization is very effective in ruling out myocardial infarction when a patient presents with chest pain, and, therefore, it may not be clinically or financially necessary to develop a short-stay unit. Alternatively, the data may show that a large number of patients are being admitted to the critical care unit and put through many diagnostic tests, only to have a myocardial infarction ruled out within 24 hours.
The case manager will also be exchanging data with the payer during the implementation and planning phase. Primarily, this will be clinical information about the patient, especially in regard to continuing acute care and ongoing needs postdischarge. Certainly, case managers must be knowledgeable about the clinical condition and needs or wants of the patient. At the same time, they must also be knowledgeable about length of stay, benchmarks, and trends for the types of patients included in their caseloads. This will assist with the brokering of services and negotiation with payers.
It is also important to know what guidelines or standards the payer uses as criteria for admissions, continued stay, and discharge. The length of stay expected by the payer may not seem reasonable in light of the patient's clinical condition. Knowledge of the guidelines being used can help the case manager differentiate the ideal condition the guideline describes from the real life situation or, if necessary, assist in explanations to patients and providers as to why acute care is no longer necessary.
Since this article focuses on human elements and outcomes with respect to health care data, it should be emphasized that patients benefit and improved outcomes are supported by good working relationships between case managers and payer representatives. Whether on-site or telephone connections are made, the patient's best interests always must be kept in mind. The case management process cannot proceed if there is continued disagreement about what is covered, what should be provided, and how long the patient should stay. It is much more effective to "get it right" the first time than to engage in lengthy denials, reviews, complications, or readmissions.
Face to face meetings or forums with local payer case managers can be very helpful for all. Expectations can be shared along with pathways or disease management programs. Discussions about groups of patients or particular diagnoses can expedite the provision of care rather than having extensive amounts of time consumed by one case.
CASE MANAGEMENT AND THE CONTINUUM OF CARE
Discharge planning and care continuation must be a major emphasis for the case manager. As the patient's discharge draws nearer, it is useful to take another look at the risk assessment list to examine possible complications or chances for system failure that might lead to read mission.
As readmission studies are underway, organizations are also asking: What has failed that caused another acute care episode? Because chronic diseases cause most acute admissions, and these populations are aging, this is a critical question to answer.
Some possible answers include:
* The patient and family did not have enough information to manage the medical condition.
* The benefits of managing the medical condition did not seem worth the effort for the patient.
* Financial considerations took precedence.
* Intervention has always been emphasized; prevention has not.
* Caregiver or other support system was lacking.
* Follow-up was not effective or was not arranged.
* The correct support connections in the community were not made for this patient.
Communication with those helping the patient after discharge will eliminate or alleviate some of these problems and prevent readmissions. It will also help the case manager to serve patients more effectively. Outcome measures from home care companies, rehabilitation programs, outpatient physical therapy, and other services should be identified when possible. Which provides more timely service? Which has easy to use equipment? How is patient education given? What is the infection rate for infusion services? What emergency equipment or personnel are available in case of a problem? The case manager can be an advocate for patient choice and care in these instances.
Innovative programs may also be arranged. For example, visiting nurses may provide a home visit for new mothers who choose to stay less than required or legislated time periods. This benefits the new baby and mother as well as providing a chance to evaluate the safety and adequacy of the home situation and prevent complications or readmission.
MONITORING AND EVALUATION
Despite successful efforts to lower the lengths of stay for its total joint population, one central New York hospital has found that a service delay occurred as the patients and physicians sought a well-respected rehabilitation unit for postdischarge care. As this unit was often at maximum capacity, it was difficult to admit patients. Ongoing monitoring of lengths of stay revealed that patients were staying slightly longer in the acute setting.
This acute care facility decided to contract with a rehabilitation center for case management services. A case manager from the center calls patients prior to surgery, determines the postoperative needs, and whether the physician has recommended rehabilitation. The patient selects a rehabilitation center and may tour it and make admission arrangements ahead of time. The case manager calls the chosen rehabilitation center to alert them that a bed will be needed based on the date of surgery. The hospital now exchanges data with the rehabilitation center regarding length of acute stay, length of rehabilitation stay, cost per case in both settings, and readmissions, complications, and infections.
It is now being recognized that patients with chronic illness can benefit from ongoing monitoring and follow-up. 4,9 Programs in which case managers monitor patients using telephone follow-up, home visits, or clinical programs are showing effective results, especially for diabetes, congestive heart failure, asthma, chronic obstructive pulmonary disease, and renal disease. Monitoring the patient's clinical status is usually combined with educational components and community support to provide the encouragement and confidence needed for patients to take a more active role in health management.
Functional status is another important area for ongoing monitoring of outcomes. Has the patient's physical and/or emotional status improved during the acute care episode and have provisions for continued improvement post discharge been put in place? There are a number of reliable, valid tools for measuring changes in abilities to perform activities of daily living or diagnosis-specific status. These can provide an ongoing monitoring capability if data are collected prior to, during, and after acute care.
Other tools that aid in evaluation include pathways that are phased, continuing on into the postdischarge period and encompassing ongoing follow-up. As partnerships occur between acute care, physician offices, long-term care, and home care, this method of follow-up will undoubtedly increase.
Case management is being touted as a way to bridge many of the gaps occurring in health care today. Because the case manager communicates and intervenes with patients, providers, and payers throughout the continuum, the opportunity for better outcomes is presented and barriers to smooth, effective care are removed. The use of aggregate data parallels the overall health perspective used by the case manager. Instead of relying on hunches or information from small internal samples, the application of data can equip the case manager to discuss patient needs, negotiate and arrange services, and monitor outcomes for all participants in the health care system.
© 1999 Aspen Publishers, Inc.