Executive Summary

Since readmissions often result from inappropriate discharge planning or discharging patients when they’re not prepared to manage themselves after discharge, one solution is to increase the involvement of case managers in the transition.

• Under the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) provides financial incentives for health systems to prevent readmissions.

• Community and hospital case managers need to communicate more effectively to ensure a seamless transition of care.

• Having quarterly meetings with high volume community partners can help.


Healthcare transitions have always been critical in case management, but the Affordable Care Act (ACA) has pushed transitions to the top of the priority list for many healthcare providers.

“ACA’s penalties surrounding readmission rates and a lot of other forces have brought it to everyone’s attention,” says Cheri Bankston White, RN, MSN, director of clinical advisory services at Curaspan Health Group in Newton, MA.

“When we drill down to it, the reasons for readmissions are inappropriate discharge planning or discharging patients that were not necessarily prepared to manage themselves after discharge,” White says. “Everyone is starting to recognize that the case manager holds the keys to the kingdom.”

This ACA era is an exciting time for case management, White notes.

“We’re just in the middle of everything right now,” she says. “Even though we are super busy, we need to embrace the change and start to reach out to community partners, taking the initiative to engage the payers and providers.”

Case managers now have more of a role after discharge and into the community, she adds.

Another change has been increased communication between hospital case managers and case managers in other settings, White notes.

Pre-ACA, acute care case managers were satisfied with managing their own cases, but were less concerned with following up on patients post-discharge. That’s changed with Medicaid and Medicare incentives to prevent readmissions, she says.

“So case managers need to be in touch with payers and post-acute providers to understand the best way to handle moving patients from one level of care to the next,” White explains.

Communication between hospital and community CMs can take place automatically and electronically, but it has to happen, she adds.

With everyone invested in better outcomes, CMs need to pay attention to relationship-building. “We need to build this into our orientation process and do things creatively,” White says.

“I recommend that new case managers shadow people in different settings and learn about the regulatory pressures and criteria that community partners are dealing with,” White says.

For instance, the following are some of the things new CMs need to learn:

• what it takes to make a smooth transition,

• which information is crucial for each health provider partner to receive, and

• what the CM needs to know about the community partner to be successful.

CMs also can learn about the contracts providers have with payers, information that helps CMs direct staff to necessary tasks, White adds.

“If I have a contract with an insurer and that contract states that I’m going to call and deliver a review every day, regardless of the diagnosis, then my staff needs to understand that expectation,” she says.

The case management world — while always requiring broad knowledge of community services — has gotten even bigger. CMs now need to know of community transport companies and care coordination organizations, as well as home health agencies and skilled nursing facilities. So they need to reach out to these organizations, White says.

“What I find successful is to have quarterly meetings with your high volume community providers, and at those meetings be prepared to discuss specifics,” White explains. “They need to be on the same page with what your goals are, and you need to listen to see if there are any things that are new in the industry — anything you need to help with.”

The main idea is for CMs across the care continuum to work together to improve outcomes for their shared patient populations. To do so, they need to share information and develop a more productive and powerful relationship, White says.

“I think sometimes we get so busy, we forget to keep on top of the latest rules and regulations,” she adds. “So we need to educate our staff on what’s going on out there.”

For instance, it’s helpful to give staff information in digestible formats and in easy-to-read articles, she says. “It’s our responsibility as leaders to educate our staff,” White says.

It might take effort, but it’s an investment, White adds.