New payment models require a shift in thinking
Value, not length of stay, should be the focus
Under the DRG payment system, case managers have been pressured to get patients out of the hospital as quickly and safely as possible, but that’s not the case in bundled payment arrangements, says Francois de Brantes, MS, MBA, executive director of the Health Care Incentives Improvement Institute.
Bundled payments cover an entire episode of care, including services the patient receives for as long as 90 days after discharge, and hospitals are at risk for what happens to patients during that time, he adds.
“Case managers have to look at patients’ support systems at home, the care they need, the quality of care provided by post-acute providers, and other factors that may have an impact on the quality of care, and on the total cost, which is included in the bundle,” de Brantes says.
If hospitals are going to succeed with bundled payment arrangements, they are going to have to re-engineer their clinical and operational processes and manage care in a different manner, says Karen Zander, RN, MS, CMAC, FAAN, president and chief executive officer of the Center for Case Management. “Case managers have to discharge patients to the level of care that can deliver the best value for that particular patient. In addition, hospitals have to build relationships with post-acute providers and ensure that there are case management services across the transition. It’s tough but achievable. Changing the mindset is what will be difficult,” she adds.
Case managers are the linchpin in bundled payments, adds Deirdre Baggott, PhD, MBA, RN, senior vice president of The Camden Group and expert panel reviewer for the Bundled Payment for Care Improvement Initiative (BPCI), Models 2-4.
“More today than ever, the case management role is driving the entire care team. The importance of ensuring that patients get the best care in the best setting is heightened with the Centers for Medicare & Medicaid Services’ commitment to payment reform,” she adds.
Case managers are going to have to understand all the implications of post-acute care and be collaborators and facilitators that help lead the hospital’s bundled payments arrangement, adds Beverly Cunningham, MS, RN, partner and consultant in Dallas-based Case Management Concepts.
“Case managers have to look at what internal strategies they can put in place to move patients along in a timely manner and to increase communication between the inpatient and outpatient environment in the hospital as well as between the hospital and the next level of care,” Cunningham says.
In order to help their hospitals succeed under bundled payments, case managers have to start thinking about the costs for the entire episode of care, says Toni Cesta, RN, PhD, FAAN, partner and consultant in Case Management Concepts. “Case managers are going to have to understand what the right resource consumption is for each individual patient and work with physicians to keep the costs in line,” she adds.
For instance, if a patient is likely to be able to manage at home with outpatient rehabilitation, that should be the option the case manager suggests, even if the patient’s insurance will pay for a subacute stay. Or, a patient may be able to stay a day or two longer, receive inpatient physical therapy, and avoid going to a skilled nursing facility, she adds.
“Case managers should be taking a far greater leadership role in the decision-making concerning patient care and discharge destinations. Finding an appropriate post-acute provider who can meet a patient’s individual needs is incredibly important and case managers have to go beyond simply looking at what is available,” de Brantes says.
A key strategy for success in the new world of healthcare is to focus on your post-acute care providers and develop close working relationships with them, Cunningham says.
When hospitals are sharing financial risk, there’s no way they can succeed if they aren’t a team player and collaborate with other entities throughout the continuum, Baggot adds.
While many healthcare organizations have initiated collaborations with post-acute providers, many have yet to begin the work of building a post-acute network, Baggot says.
“Collaborating with post-acute providers is going to be crucial in the future and the role of case managers becomes critical in referring patients to the providers who deliver high-quality care and to ensuring smooth transitions of care,” Baggot says.
Be informed about the skilled nursing facilities, long-term acute care hospitals, rehabilitation facilities, and home care agencies that provide services to your patients after discharge, Cunningham says. Understand their readmission rates, their quality metrics, and what specialized services each one provides and use the information to develop discharge plans, she adds.
“We’ve always given short shrift to post-acute quality indicators, but we need to be more informed and cautious when the hospital is at risk for patient outcomes. Make sure that post-acute providers have a good track record of providing the care the patient needs,” Cesta adds.
Case managers would benefit from profiling potential post-acute partners from cost, quality, and patient experience standpoints, Baggot suggests. “Under bundled payments, case managers have a heightened responsibility to ensure the value of post-acute providers and guide patients across the continuum,” Baggot says.
Patients will still have a choice of providers, but case managers may elect to use one of the new transparency tools in an effort to better inform patients and family members as they make their decisions, Baggot says.
Transitions of care are critical, Baggot says. “We have evidence to support that the first post-acute setting correlates with the total cost of care. There must be significant coordination across every care setting,” she adds.
Some participants in the BPCI are outsourcing the care coordination services during the post-discharge period, Zander says. “Ultimately, any time you outsource to another company, it costs more money than if you create your own program. I am for having inpatient and outpatient case managers under one big umbrella for a health system,” she says.
One new role that is emerging is the patient navigator, whose job is to ensure care transitions go smoothly and to manage readmission risk, Baggot says. Navigators communicate with patients once they get home, ensure that they connect with their medical home, and make sure that providers at the next level of care have the information they need.
“This is a support role for the case managers. Navigators are not required to have the extensive clinical knowledge that case managers do. Primarily, navigators handle the logistics, such as making sure the discharge information gets to the patient’s primary care physician,” Baggot says.
Having an integrated case manager who follows patients from admission through the continuum of care may be effective, but it’s difficult to develop the role unless the provider owns all of the entities in the continuum of care, Baggot says. “If the system doesn’t own all of the assets, the question becomes who bears the cost of the role. The role of the integrated case manager is a great strategy in ensuring smooth transitions in care. The challenge is how to operationalize it across partnering entities,” Baggot says.
Under the DRG payment system, case managers have been pressured to get patients out of the hospital as quickly and safely as possible, but that’s not the case in bundled payment arrangements.
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