Somebody has to coordinate the post-discharge care now that hospitals are beginning to bear risk for what happens to patients after discharge, but inpatient case managers are already swamped and don’t have the time to do the job well, experts say.

  • Hospitals need to develop a new role of transitional case manager, RN navigator, or some other title and hire a separate person to handle discharges and follow-up for complex patients.
  • The job requires someone with experience in the inpatient setting and knowledge of community resources and how to refer patients to them.
  • The key to success under payment reform is communication within the hospital and between all levels of care so everyone who touches the patient has complete information.

As hospitals assume financial risk for what happens to patients during the entire episode of care, responsibility for care coordination can’t stop at discharge.

Somebody has to make sure patients have a smooth transition, have everything they need to avoid returning to the hospital, and that the provider at the next level of care has details about the hospital stay. So who’s going to do all that care coordination?

Hospitals can’t keep piling work on inpatient case managers, says Jean Maslan, BSN, MHA, CCM, ACM, senior managing consultant for Berkeley Research Group, with headquarters in Emeryville, CA.

“They already have so much on their plate that they don’t have time to give post-acute care coordination the attention it deserves,” she adds.

“Case managers can do only so much. In most hospitals, the traditional roles of the unit-based case managers and social workers aren’t adequate to handle all of the responsibilities that come from payment reform. It’s time to look at the critical needs and create new roles,” says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.

Some hospitals are already establishing new positions to help with the increasing care coordination responsibilities that result from new reimbursement processes.

They’re giving the new roles a variety of titles: transitional case manager, nurse navigator, transition manager, transition coordinator, transition coach, or other titles, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.

“It doesn’t matter what people are called. What’s important is that hospitals have someone whose main responsibility is facilitating transitions. Handling complex transitions is too much work for the regular staff, particularly since payers are turning more and more to reimbursing for entire episodes of care, which can extend as long as 90 days after discharge,” she adds.

Case managers focused on ensuring a successful discharge can have a big effect on bundled payments initiatives, Maslan says. “With bundled payments, hospitals have to share dollars with post-acute providers. If they don’t manage patients efficiently, it will have a financial impact. It’s in the best interest of the hospital to have a nurse navigator to follow the patients after discharge, which has been shown to cut down on readmissions, repeat emergency department visits, and duplication of services,” she adds.

CMS has been progressively adding episodes of care to its bundled payments program since it launched the voluntary Bundled Payments for Care Improvement in 2013. Bundled payment projects for patients with total knee and hip replacements, cancer treatment, acute myocardial infarction, coronary bypass surgery, and hip fractures are either underway or in the works. In addition to the CMS programs, commercial managed care payers are launching their own bundled payments arrangements.

CMS also has proposed major changes in the discharge planning requirements of the Medicare Conditions of Participation that are likely to increase the workload of hospital case managers. Among the requirements are developing a discharge plan for all patients, making follow-up phone calls to all discharged patients, and having discharge instructions in the hands of the primary care provider within 48 hours of discharge. CMS issued the proposed rule in Nov. 2015 and asked for public comments by Jan. 3, but did not set a date for implementation. (For more information, see the February 2016 issue of Hospital Case Management.)

“If you consider only the bundled payments requirements, hospitals are going to have to develop complex discharge plans for patients with complex needs being transitioned to the next level of care. When you take other payment reform, such as Medicare spending-per-beneficiary and value-based purchasing and the CMS proposed discharge planning rule into account, it sets the scene for every case management leader to begin to consider that transitional case management role,” Cunningham says.

Hospitals need a point person to help coordinate care across the continuum, Maslan says.

“The nurse navigator is the future of nursing. It’s an exciting position that has been needed for a long time. The healthcare system is disjointed for many patients. People use the emergency department too much, they miss physician appointments, and often receive duplicate services from different providers. The nurse navigator can guide the patient through the continuum and subsequently save healthcare dollars,” Maslan says.

“The nurse navigator’s work should encompass the whole patient: psychosocial issues, medical problems, medication, and nutrition,” she adds. “They are the point person when the patient needs support with dietary issues, emotional problems, financial needs.” When a nurse navigator is coordinating care, patients and family members have one person to contact when they have questions or need help, which increases patient satisfaction, she says.

“Care coordination cannot encompass only the hospital stay anymore,” says Peggy Rossi, BSN, MPA, CCM, continuity of care service director for the 287-bed Kaiser Permanente Sacramento Medical Center and consultant for the Center for Case Management.

Case management directors should start trying to identify one staff member who can move into the role of complex case manager or inpatient navigator once the role is developed, Rossi says.

“We all need to be taking a hard look at all the changes in the healthcare delivery system that are in the works and start to prepare for them now. Waiting until later could have a dire effect on the hospital’s bottom line,” Rossi says.

So far, the only mandatory bundled payments initiative that has been implemented has focused on patients receiving total hip and knee replacements. Both are scheduled procedures and most have predictable outcomes, Cunningham says. But the next round of bundled payments are not going to be so simple to implement, she adds.

“CMS’ next step creates bundled payments for myocardial infarction, coronary artery bypass graft surgery, and fractured hips. These patients come in through the emergency department and have complex needs that require we take a totally different look how these patients transition to the next level of care,” she says.

The next bundled payment program, which is slated to begin July 1, 2017, is likely to be a challenge for all hospitals, but especially for rural hospitals with a high Medicare population, Cunningham points out. “Smaller hospitals may not offer orthopedic surgery or coronary artery bypass graft surgery, but they are likely to have patients come into their emergency department with acute myocardial infarction and fractured hips. Since they will be at-risk for patients for 90 days after discharge, they will need transitional case management,” she says.

Hospitals have to focus their efforts on the most complex patients, Cesta says. “Having a transition case manager for every patient isn’t practical. Case management leaders need to determine which population of patients need it most,” she adds.

Case managers in the new role should have different day-to-day duties from the rest of the case management staff, Rossi says. Case managers in the role should have the time to conduct in-depth assessments and research the appropriate community resources, she says.

“Creating and carrying out a discharge plan for a patient with complex needs is a time-consuming process that can take hours, or even days. The regular case managers often don’t have that kind of time, so work may go untouched or it must be assigned to another case manager,” Rossi says.

In addition to developing a complicated discharge plan, case managers in the new role will need to educate patients and family members on how to navigate the post-acute healthcare maze, she adds. “This will prepare the patients and family to manage the medical needs that may be long-term or, in some cases, life-long,” she says.

To make the case for adding the new position, case management leaders need to be able to demonstrate return on investment to the hospital leadership, Cunningham says.

“Point out all of the initiatives that make it imperative for patients to have an appropriate discharge plan and effective transition to the next level of care. Medicare spending-per-beneficiary, readmission reduction, bundled payments, and CMS’ proposed discharge planning rules make it clear that transition case managers are needed,” she says.

Analyze data to determine the opportunities for improving transitions and where the hospital can get the biggest value, then try it out with that population. Start with one transition case manager and learn from his or her experiences, Cunningham says.

Maslan suggests piloting the nurse navigator initiative on a high-risk unit, such as one with a lot of heart failure patients, and running the pilot for at least three months.

“The pilot has to last long enough to produce enough data to track, trend, and make your case to the senior leadership,” she says.

Compare outcomes during the pilot with those from the same period of time before the pilot began. Include the cost savings the nurse navigator produced, improvement in quality measures, and patient satisfaction scores, she says.

“Hospitals are already losing revenue when heart failure patients are being readmitted. It is possible to show savings to the hospital after a fairly short period of time,” she says.