CCM

Level of care describes the intensity of services a client requires; the care setting is where those services are delivered. The case manager’s task is to match the client to the least restrictive, most cost-effective setting that safely meets clinical need, and to move the client up or down the continuum as the condition changes.

Life-threatening instability; continuous

monitoring

24-hour physician and nursing care; diagnostic and treatment

intensity

Prolonged medical complexity or intensive therapy

Daily skilled nursing or therapy after an acute stay

Intermittent skilled care or supportive care in a residence

Lowest intensity; client lives independently in the community

Inpatient, Observation, and Outpatient Status

A hospitalized client may be an inpatient or an outpatient receiving observation services, even though both occupy a hospital bed. Status determines how the stay is billed and has major consequences for the client. Under the Medicare Two-Midnight Rule, inpatient admission is generally appropriate when the admitting practitioner expects the client to need medically necessary hospital care spanning at least two midnights; shorter expected stays are usually handled as observation or outpatient care, with exceptions for procedures on the inpatient-only list.

Inpatient

Observation (Outpatient)

Formally admitted by a practitioner’s order. Billed under Medicare

Short-term monitoring and treatment to decide whether admission

Part A (inpatient deductible). Days count toward the 3-day

is needed. Billed under Part B (coinsurance per service).

qualifying inpatient stay required for Medicare SNF coverage.

Observation time does not count toward the SNF 3-day stay. Medicare beneficiaries in observation longer than 24 hours receive the Medicare Outpatient Observation Notice (MOON).

When a Medicare client in observation will likely need SNF care, the case manager explains the financial impact early, reviews the medical record against admission criteria with the physician advisor, and explores alternatives if the qualifying stay will not be met. Surprise SNF bills after an observation stay are a common source of client complaints.

Setting	WhoItServesandKeyFeatures
Emergencydepartment	Unscheduledacutecare UnderEMTALA anypersonwhocomestoahospitalemergencydepartment . ,
	mustreceiveamedicalscreeningexamandstabilizingtreatmentregardlessofabilitytopay EDcase .
	managers redirect nonurgent use and arrange follow-up .
Acutecarehospital	Short-term diagnosis and treatment of acute illness injury and surgery with 24 -hour physician and , ,
Long-term acute care hospital(LTACH)	nursing coverage . 1 Hospital -level care for medically complex clients who need extended acute care such as prolonged , mechanicalventilationweaning complexwounds ormultisystemfailure Medicarerequiresanaverage , , . lengthofstaygreaterthan25days .

Caresettingsacrossthecontinuum(Continued)

Setting	WhoItServesandKeyFeatures
Inpatientrehabilitation	Intensive interdisciplinaryrehabilitationunderphysiciansupervision Theclientmustbeabletotolerate , .
facility(IRF)	andbenefitfromabout3hoursoftherapyadayatleast5daysaweek(or15hoursover7days)and
	needatleasttwotherapydisciplines oneofthemphysicaloroccupationaltherapy Commonforstroke , . ,
	spinalcordinjury braininjury amputation andmajormultipletrauma , , , .
Skillednursingfacility	Dailyskillednursingorrehabilitationthatcanbeprovidedonlyonaninpatientbasis MedicarePartA .
(SNF)	covers up to 100 days per benefit period after a 3 -day qualifying inpatient stay (days 1–20 in full ,
	coinsurance for days 21–100); custodial care alone is not covered .
Subacutecare	AlevelbetweenacutehospitalandtraditionalSNFcareforclientswhoarestablebutneedcomplex
	servicessuchasIVtherapy woundcare orventilatorcare;oftenaunitwithinaSNForhospital , , .
Homehealth	Intermittentskillednursing therapy andaideservicesinthehome Medicarecoveragerequiresthatthe , , .
	clientbehomebound needintermittentskilledcare andbeunderaplanofcareestablishedand , ,
	reviewed by a physician or allowed practitioner with a face-to-face encounter , .
Grouphome	Smallresidentialsettingwithsupervisionandsupportforpeoplewithintellectualordevelopmental
	disabilities seriousmentalillness oryouthinthechildwelfaresystem , , .
Assistedlivingfacility	Residential setting offering help with ADLs medication assistance meals and 24 -hour supervision but , , ,
	notcontinuousskillednursing;usuallyprivatepayorMedicaidwaiver .
Adultdayservices	Daytimesupervision socialization andsometimeshealthservicesforadultswholiveathome;also , ,
	providescaregiverrespite .
Hospice(homeorfacility)	Comfort-focused care for terminal illness delivered wherever the client lives: home assisted living , ,
	nursingfacility oraninpatienthospiceunit , .
Outpatientand	Physicianoffices clinics ambulatorysurgerycenters outpatienttherapy dialysis andinfusioncenters , , , , , .
ambulatorycare

Distinguish IRF from SNF by therapy intensity: a client who cannot tolerate 3 hours of therapy a day, or who needs daily skilled nursing more than intensive rehab, belongs in a SNF. A client who needs hospital-level medical care for weeks, such as ventilator weaning, belongs in an LTACH.