With new initiatives that put hospitals at risk for what happens to patients for as long as 90 days after discharge, case managers need to look at resources in the community when creating a discharge plan.

  • Assess your patients’ medical and psychosocial needs after they leave the hospital and make sure they are connected with community services that can help them stay safe and healthy.
  • Gather a comprehensive list of community organizations that can provide assistance and support for patients after discharge and create alliances with them.
  • Assess your patient population and identify any gaps in transitions, then work to fill them, even if your hospital isn’t yet at risk for patients after discharge.

Remember when “coordinate care beyond hospital walls” meant collaborating with skilled nursing facilities and home health agencies? Not anymore.

With new initiatives such as bundled payments and Medicare spending per beneficiary, CMS and other payers put hospitals at risk for as long as 90 days after the patient is discharged from the hospital. This means case managers are going to have to expand their care coordinating efforts to organizations in the community that can help meet patients’ medical and psychosocial needs long after they leave the hospital.

“Traditionally, case managers were responsible for patients from curb to curb. Now, as the focus shifts to transitions of care and hospitals become at risk for what happens to patients after discharge, case managers need to look at the bigger picture of the entire community when they plan the post-acute short-term and long-term arrangements for patients,” says Cheryl Warren, MS, RN, CMAC, chief clinical integration officer for Hallmark Health, a network of community hospitals and health centers in the Boston area.

CMS launched its first bundled payment initiative, the voluntary Bundled Payments for Care Improvement, in 2013, and has been steadily adding episodes of care. The mandatory Comprehensive Care for Joint Replacement bundled payment initiative began April 1 in 67 markets, and the Oncology Care Model bundled payment program with 200 physician groups and 17 payers launched July 1. CMS has proposed a mandatory bundled payments pilot project for acute myocardial infarction and coronary bypass surgery to begin July 1, 2017, and announced plans to add hip and knee fractures to the mandatory orthopedic bundled payment program.

The Medicare spending-per-beneficiary initiative, the Value-Based Purchasing Program, and the readmission reduction program all base reimbursement at least partially on what happens after discharge. In addition, CMS’ proposed discharge planning conditions of participation includes requirements that case managers take available community resources into consideration when creating a discharge plan.

“The writing is on the wall: Payment reform is not going to go away, and hospital case managers need think about whether their patients are going to need help with another transition after the initial post-acute services are complete,” says Cheri Bankston, RN, MSN, director of clinical advisory services for Curaspan, a subsidiary of naviHealth.

To survive in the changing healthcare market, hospitals are going to have to look at new ways of doing things, adds Angie Roberson, MSN, RN, ACM, director of case management at Spartanburg (SC) Regional Health System.

“As we try to shift from volume to value in the healthcare industry, the key is to go beyond collaborating with the post-acute providers and to be involved in the community. It means more than collaborating with what we think of as healthcare providers — it means developing relationships with Meals on Wheels, United Way organizations, and local charitable organizations,” Roberson says. (For more details on Spartanburg Regional Health System’s community partnerships, see related article in this issue.)

Hospitals are becoming increasingly at risk for the cost of patient care after discharge, points out Donna Zazworsky, RN, MS, CCM, FAAN, principal of Zazworsky Consulting in Tucson, AZ. This means that case managers need to develop relationships with community resources that can help meet patients’ needs in the community after discharge, she adds.

“Without question, in today’s healthcare environment it is critical for hospitals to work with community agencies and to ensure that there is some kind of care coordination for patients who need it after they are discharged,” Zazworsky says.

Even if patients are being discharged to home, case managers need to have transition care in place to create a seamless handoff from the hospital to the patient’s primary care provider, or, in some cases, a federally qualified health center, Zazworsky adds.

Bankston strongly recommends that case management directors begin immediately to educate their staff about changes in reimbursement and how to coordinate care transitions more efficiently. “Many case managers are unclear about payment reform and how bundled payments and other new initiatives can impact the hospital. Case management directors need to make sure their staff understands the impact of these changes and should consider redesigning the discharge process to create more efficient workflows to transition patients to the right care at the right time,” she says.

“Most patients experience multiple transitions — from hospital to post-acute care facility, and from post-acute care facility to home — and support is needed at each step of the recovery,” Bankston says.

For instance, when patients receive home health services, they may need assistance from organizations like housing assistance or Meals on Wheels after they are discharged from home health.

Another transition challenge is the gap between discharge and when the home health provider arrives, Zazworsky adds. Many times, the home health agency can’t send anyone to the home until several days after the patient is discharged, she says. The first few days after discharge are the most critical, and if there is a gap, patients may end up back in the hospital, she adds.

“We used to focus on shortening the length of stay in the hospital and other inpatient hospital-focused metrics, but now with bundled payments and other initiatives that pay for the entire episode of care, we need to look at length of stay and other quality metrics in post-acute facilities and consider additional alternatives for patients being discharged,” Warren says.

She advises case managers to consider the community programs that are available to keep patients at home and healthy. For instance, some patients may be able to go home if they get help with grocery shopping and housekeeping she adds.

“There is pressure to move patients out of acute care, but skilled nursing facilities and home health agencies aren’t always the best discharge setting for every patient. Case managers are strengthening their relationship with community resources that can help patients return home and stay there safely,” Bankston says.

The reality is that it takes more time for case managers to arrange community services than it does to arrange a transfer to another facility, Bankston points out. However, linking patients with community agencies and providers can increase patient satisfaction and improve outcomes at a lower cost, Bankston says.

“It can be disconcerting for patients, especially the elderly, to go to a completely new environment. If they can be at home in a familiar setting or surrounded by family and friends, they have better outcomes. Case managers can make that happen by linking them to community organizations that can meet their needs,” she says.

“There’s not a road map that tells you what you should do to achieve excellent outcomes. Every community has to develop its own individual strategy,” Roberson adds.

Roberson points out that while there are numerous care transition models, there’s no model that fits the needs of every patient.

“When you talk about care transitions into the community, one size doesn’t fit all. Hospitals have to come up with multiple strategies and interventions in order to meet the needs of everyone. Case managers have to figure out how to provide the correct intervention for each individual patient to get the outcomes we need. Then we have to come up with a way to fund it and be fiscally responsible with the limited dollars we have,” Roberson says.

The traditional relationship between hospitals and post-acute providers has to change, Warren points out. “In the past, hospitals and post-acute providers had an informal relationship built around marketing and referrals. Hospitals referred patients, and the post-acute providers screened them and accepted them or not,” she says.

Now, hospital case managers need to be working with the hospital’s data analyst to determine where patients are going, lengths of stay for each provider, readmission rates, and other quality metrics, she adds.

“Case managers have to work more closely with everyone — not only post-acute facilities, but families and physicians as well. With bundled payments, hospitals need to follow the patients for up to 90 days post-acute and monitor the quality of care they’re receiving along with their resource utilization,” she says.