Beginning this year, CMS is paying hospitals a bonus or extracting a penalty depending on the quality of care they deliver. Hospitals administrators know that the difference between getting more and getting less from CMS will depend on how well all staff perform, but they might not realize that perhaps the most critical staff members in improving quality and patient experience are case managers.
Vitally important in healthcare today, case managers play such an essential role in hospitals and health systems that they are almost becoming the face of care. In Jacksonville, Fla., St. Vincent's Healthcare has sponsored a billboard along Interstate 95 even touting the good work of one of its certified case managers in helping to ensure that patients get the best care.
No one disputes the contributions of physicians, nurses and other providers, but very few — if any — of these clinicians are responsible for ensuring that patient care is delivered appropriately to every patient and that the hospital gets reimbursed for that care. Only case managers are responsible for both of these essential functions. As a result, case managers are making significant contributions to the bottom line in hospitals and health systems.
Here are five ways case managers improve hospital performance.
1. Improving outcomes. Foremost in any case manager's job description is improving patient outcomes, and hospitals and health systems are leaning on them heavily for this indispensable task, particularly given CMS' focus on reducing readmissions. The University of Connecticut's John Dempsey Hospital, in Farmington, for example, has case managers schedule appointments for patients in the hospital’s heart failure clinic. This initiative has helped the hospital to reduce its 30-day heart failure readmissions, according to a November 2012 article in Hospital Case Management.
In Madison, Wisconsin, nurse case managers implemented a transitional care program to cut readmissions at the William S. Middleton Memorial Veterans Hospital. The case managers help patients manage their medications and keep in touch with patients by phone after discharge. Called the Coordinated-Transitional Care Program, the initiative helped the hospital save $1,225 per patient, according to an article in the December 2012 issue of Health Affairs.
2. Reducing readmission risks. Case managers make a bottom-line difference in healthcare organizations because they have a keen focus on improving care coordination and eliminating gaps in care that lead to unnecessary readmissions, according to the Commission for Case Manager Certification. Here's an example. Last fall, physician executives from Aetna wrote about how the health insurer was using case managers to improve outcomes for 750 Medicare beneficiaries in a collaboration with NovaHealth, a physician group in Portland, Maine. In the article in the September 2012 Health Affairs, the authors reported 56 percent fewer readmissions than statewide unmanaged Medicare populations, and the total per member per month costs for Aetna's Medicare members were 16.5 percent to 33 percent lower than costs for other members, the authors wrote.
3. Eliminating avoidable days. In the same article, the authors wrote that the Medicare beneficiaries who were working with the case managers in collaboration with NovaHealth had 50 percent fewer hospital days per 1,000 patients and 45 percent fewer admissions. The passage of the Patient Protection and Affordable Care Act has led hospitals and health systems to develop new ways to foster patient-centered, accountable care, the authors wrote. One way to do so is to implement models of care built on care management and coordination, they added.
4. Enhancing claims management. In addition to ensuring that each patient gets appropriate and timely care, case managers also must ensure that any patient's hospital stay, or any part of that stay, is medically necessary, delivered in the most appropriate setting and is not custodial in nature.
If CMS, the state Medicaid program or a private health plan decides a patient's stay is not medically necessary, the hospital or health system can lose thousands of dollars in reimbursement. In addition, when a patient learns that Medicare, Medicaid or a commercial insurer has declined to pay for hospital care, such news is likely to be particularly troubling for patients and family members and almost certainly will result in a negative patient experience. Given CMS' emphasis on patient experience, hospitals don't want negative reports on patient surveys.
In most hospitals, it is the case manager's responsibility to notify the patient about insurers' decisions regarding medical necessity and ensure that the patient receives a Hospital-Issued Notice of Noncoverage. Then, the case manager advocates on the patient's behalf to get the insurer to reverse its decision, if possible.
5. Boosting core competencies under the PPACA. Ensuring that each patient has insurance coverage for every day in the hospital has long been a part of case managers' job functions. Today, however, health reform has brought a new function: Boosting core competencies under the PPACA. CMS bonus payments and financial penalties demonstrate the important role of case managers under the PPACA because CMS bases its criteria for bonuses and penalties on factors that case managers affect, such as patient experience, quality of care and readmission rates.
Under the PPACA, healthcare organizations are required to improve or launch preventive care initiatives among covered populations and develop methods for population health management. These preventive care programs are designed for at-risk populations who have costly chronic conditions such as asthma, chronic obstructive pulmonary disease, diabetes, depression and heart failure. These are conditions where case managers can make a significant difference by motivating patients to improve their health status and thus potentially reduce hospitalizations. When hospitalizations decline, the ability of case managers to help hospitals and health systems gain bonuses and avoid penalties will become that much more important.
Hospital and health system executives are beginning to realize the economic consequences of the PPACA and recognize that if ever there was a time to use the expertise, skills and knowledge of a proven workforce such as case managers to enhance their processes and bottom line, that time is now.
Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, is principal of EFS Supervision Strategies, LLC, in Burke, Va. She also serves as adjunct faculty for George Mason University's College of Health & Human Services and is director of social work education for Athena Forum LLC. She also served as a commissioner for the Commission for Case Manager Certification and as past chair of the commission's Ethics & Professional Conduct Committee.
Mindy Owen RN, BSN, CRRN, CCM, is a principal with Phoenix HealthCare Associates, LLC, in Coral Springs, Fla., and is vice president of education for Athena Forum LLC. She also is past president of the Case Management Society of America and past chair of the Commission for Case Manager Certification.
Tom Rasmussen is the CEO and publisher of Athena Forum, LLC, in Rockville, Maryland. AthenaForum.com is a 4,000-page online course curriculum awarding 400 continuing education units for nurses, social workers and case managers (ACM and CCM). Hundreds of hospitals nationwide subscribe to Athena Forum to educate staff and improve hospital performance.
Vitally important in healthcare today, case managers play such an essential role in hospitals and health systems that they are almost becoming the face of care. In Jacksonville, Fla., St. Vincent's Healthcare has sponsored a billboard along Interstate 95 even touting the good work of one of its certified case managers in helping to ensure that patients get the best care.
No one disputes the contributions of physicians, nurses and other providers, but very few — if any — of these clinicians are responsible for ensuring that patient care is delivered appropriately to every patient and that the hospital gets reimbursed for that care. Only case managers are responsible for both of these essential functions. As a result, case managers are making significant contributions to the bottom line in hospitals and health systems.
Here are five ways case managers improve hospital performance.
1. Improving outcomes. Foremost in any case manager's job description is improving patient outcomes, and hospitals and health systems are leaning on them heavily for this indispensable task, particularly given CMS' focus on reducing readmissions. The University of Connecticut's John Dempsey Hospital, in Farmington, for example, has case managers schedule appointments for patients in the hospital’s heart failure clinic. This initiative has helped the hospital to reduce its 30-day heart failure readmissions, according to a November 2012 article in Hospital Case Management.
In Madison, Wisconsin, nurse case managers implemented a transitional care program to cut readmissions at the William S. Middleton Memorial Veterans Hospital. The case managers help patients manage their medications and keep in touch with patients by phone after discharge. Called the Coordinated-Transitional Care Program, the initiative helped the hospital save $1,225 per patient, according to an article in the December 2012 issue of Health Affairs.
2. Reducing readmission risks. Case managers make a bottom-line difference in healthcare organizations because they have a keen focus on improving care coordination and eliminating gaps in care that lead to unnecessary readmissions, according to the Commission for Case Manager Certification. Here's an example. Last fall, physician executives from Aetna wrote about how the health insurer was using case managers to improve outcomes for 750 Medicare beneficiaries in a collaboration with NovaHealth, a physician group in Portland, Maine. In the article in the September 2012 Health Affairs, the authors reported 56 percent fewer readmissions than statewide unmanaged Medicare populations, and the total per member per month costs for Aetna's Medicare members were 16.5 percent to 33 percent lower than costs for other members, the authors wrote.
3. Eliminating avoidable days. In the same article, the authors wrote that the Medicare beneficiaries who were working with the case managers in collaboration with NovaHealth had 50 percent fewer hospital days per 1,000 patients and 45 percent fewer admissions. The passage of the Patient Protection and Affordable Care Act has led hospitals and health systems to develop new ways to foster patient-centered, accountable care, the authors wrote. One way to do so is to implement models of care built on care management and coordination, they added.
4. Enhancing claims management. In addition to ensuring that each patient gets appropriate and timely care, case managers also must ensure that any patient's hospital stay, or any part of that stay, is medically necessary, delivered in the most appropriate setting and is not custodial in nature.
If CMS, the state Medicaid program or a private health plan decides a patient's stay is not medically necessary, the hospital or health system can lose thousands of dollars in reimbursement. In addition, when a patient learns that Medicare, Medicaid or a commercial insurer has declined to pay for hospital care, such news is likely to be particularly troubling for patients and family members and almost certainly will result in a negative patient experience. Given CMS' emphasis on patient experience, hospitals don't want negative reports on patient surveys.
In most hospitals, it is the case manager's responsibility to notify the patient about insurers' decisions regarding medical necessity and ensure that the patient receives a Hospital-Issued Notice of Noncoverage. Then, the case manager advocates on the patient's behalf to get the insurer to reverse its decision, if possible.
5. Boosting core competencies under the PPACA. Ensuring that each patient has insurance coverage for every day in the hospital has long been a part of case managers' job functions. Today, however, health reform has brought a new function: Boosting core competencies under the PPACA. CMS bonus payments and financial penalties demonstrate the important role of case managers under the PPACA because CMS bases its criteria for bonuses and penalties on factors that case managers affect, such as patient experience, quality of care and readmission rates.
Under the PPACA, healthcare organizations are required to improve or launch preventive care initiatives among covered populations and develop methods for population health management. These preventive care programs are designed for at-risk populations who have costly chronic conditions such as asthma, chronic obstructive pulmonary disease, diabetes, depression and heart failure. These are conditions where case managers can make a significant difference by motivating patients to improve their health status and thus potentially reduce hospitalizations. When hospitalizations decline, the ability of case managers to help hospitals and health systems gain bonuses and avoid penalties will become that much more important.
Hospital and health system executives are beginning to realize the economic consequences of the PPACA and recognize that if ever there was a time to use the expertise, skills and knowledge of a proven workforce such as case managers to enhance their processes and bottom line, that time is now.
Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, is principal of EFS Supervision Strategies, LLC, in Burke, Va. She also serves as adjunct faculty for George Mason University's College of Health & Human Services and is director of social work education for Athena Forum LLC. She also served as a commissioner for the Commission for Case Manager Certification and as past chair of the commission's Ethics & Professional Conduct Committee.
Mindy Owen RN, BSN, CRRN, CCM, is a principal with Phoenix HealthCare Associates, LLC, in Coral Springs, Fla., and is vice president of education for Athena Forum LLC. She also is past president of the Case Management Society of America and past chair of the Commission for Case Manager Certification.
Tom Rasmussen is the CEO and publisher of Athena Forum, LLC, in Rockville, Maryland. AthenaForum.com is a 4,000-page online course curriculum awarding 400 continuing education units for nurses, social workers and case managers (ACM and CCM). Hundreds of hospitals nationwide subscribe to Athena Forum to educate staff and improve hospital performance.
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