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How Effective Case Management Reduces Readmission Rates

For clinicians serving people with multiple healthcare challenges, providing effective treatment is a complex endeavor. Not only is the acuity of those with specific needs growing, but the percentage of the population afflicted by chronic overlapping conditions continues to increase. These situations make coordination of healthcare more important than ever. Therein lies the growth in the use of case managers, especially to combat readmissions.

What Is a Case Manager?

According to the Case Management Society of America, “Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost effective outcomes.”

They add, “Case management serves as a means for achieving client wellness and autonomy through advocacy, communication, education, identification of service resources and service facilitation. The case manager helps identify appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the client and the reimbursement source. Case management services are best offered in a climate that allows direct communication between the case manager, the client, and appropriate service personnel, in order to optimize the outcome for all concerned.” Case management is a vitally important function in the push to improve outcomes while controlling healthcare costs.  HealthStream blogged recently about the best skills needed for effective case management.

Case Management Can Help Reduce Avoidable Readmissions

The financial impact of readmissions penalties continues to be a significant one. RAC Monitor reminds us that “Hospitals already suffering from the financial hemorrhage of the COVID-19 pandemic will be hit again by the readmission penalty. More than 2,500, or 83 percent of hospitals in the U.S., will receive reduced Medicare funding for the 2021 fiscal year because of their readmissions from 2016 to 2019.”

CMS continues to assess a penalty per hospital that can reach as high as 3 percent of Medicare funding, “dependent on the percentage of readmissions that the facility exceeded, per Centers for Medicare & Medicaid Services (CMS) requirements. CMS continues to include the following six conditions for 30-day unplanned readmission measures: acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, coronary artery bypass graft (CABG), and elective hip or knee arthroplasty (THA/TKA). The 30-day readmission period was chosen by lawmakers as a proposed timeframe that readmissions could be attributed to hospital care. The intent of this timeframe is for hospitals to have processes and resources in place to manage patients post-hospitalization.”

RAC Monitor adds, “Reports suggest that about 25-40 percent of readmissions are preventable, highlighting the percentage of patients with chronic conditions that warrant appropriate rehospitalization. Nonetheless, the quest for creative thinking in our push for value asks health systems to think creatively in how to handle these patients. Hospitals need to evaluate how they can financially maintain as much of their payments as possible during a time when revenue is being pulled back from all areas (and during a pandemic, when elective procedures are at an all-time low). This will require an eye on process improvement, front-end quality, and revenue management to avoid back-end layoffs or broad-stoke cost-cutting measures.”

An article in Professional Case Management, a healthcare industry journal, details that a chart review of patients with chronic conditions found that “Integrated case management services were statistically significant in reducing readmission for the sample.”

How Case Management Can Work Against Readmissions

The RAC Monitor article above describes how hospitals can expand their use of case management as an effort to avoid readmission penalties they cannot afford. They write, “Most electronic medical records (EMRs) and case management departments should already include or be familiar with the key components to identify, alert, and hand off patients at high risk of readmission to outpatient case manager counterparts, ideally while the patient is still hospitalized. A proficient inpatient case management program should work closely with the hospitalist and physician teams to create an assessment and transitional care plan that decreases the risk of readmission. A case management team that is trained to identify at-risk populations will help decrease the risk of readmission by addressing issues during the hospitalization. Creating a program in which the outpatient case managers communicate with the inpatient case managers during hospitalization to collaborate as a team with the patient will ensure a safe transition at discharge. Outpatient case managers do not necessarily have to be funded at the cost of the hospital; most Accountable Care Organizations (ACOs), home health providers, and public health partners now have case management programs in place that can assist hospitals in the handoff process.”

Case Management Training

With the Affordable Care Act changing reimbursement models, case managers must ensure quality care for their patients, provide effective communication to their patients and patients’ families, and coordinate physician documentation within medical records.  They also have to understand and provide guidance on correct patient status, assist with medical necessity denial management, reduce readmissions, and overcome discharge barriers.

Decisions made and actions carried out by case managers affect the quality of patient care and organizations’ reimbursement, therefore implementing a training program is imperative to the success of your organization. Our solution was developed by experts to provide essential case management training that addresses key care coordination issues and mitigate financial and compliance risk.

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