EXECUTIVE SUMMARY

As the healthcare system undergoes tremendous changes and payers shift to reimbursement based on quality, case managers need to develop skills that go beyond day-to-day care coordination and getting patients ready for discharge.

  • For hospitals to stay afloat in the new healthcare world, case managers must reduce the length of stay and cut down on overutilization of services, but at the same time make sure patients have everything they need for good outcomes after discharge.
  • With the proliferation of new roles involving some form of care coordination, case management leadership must determine who is responsible for what and eliminate duplication.
  • Case managers should communicate regularly and work closely with their counterparts throughout the continuum to ensure that patients have what they need after discharge.

It’s a new world in healthcare.

Payers base reimbursement on quality. Hospitals increasingly are at risk for patient outcomes long after discharge. As a result, case management roles have taken on a new importance.

Now is the time for case management leaders to think about how to create the right case management role for the healthcare of the future, says Donna Hopkins, MS, RN, CMAC, vice president at Novia Strategies, a national healthcare consulting firm.

“The vision of the RN case manager has to change. If we keep doing what we’ve always done, we’re not going to move into the future. We’re on the brink of a different world in healthcare, and we have to adapt,” Hopkins says.

Medicare Spending per Beneficiary, bundled payments, and other initiatives are driving the need for cost reduction and clinical redesign across the full continuum and the pressure is only going to increase, adds Vivian Campagna, RN-BC, MSN, CCM, chief industry relations officer for the Commission for Case Management Certification.

CMS has a goal of linking 85% of Medicare fee-for- service payments to quality and shifting half of the Medicare reimbursement models to alternative payments by the end of 2018. Although the new administration may tweak the model, commercial payers are following suit, she points out.

“We’re now in a world where we are redesigning what we feel the care manager role should be,” says Margaret Leonard, MS, RN-BC, FNP, senior vice president, Medicaid, Government and Community Initiatives for MVP Health Care.

When Leonard was president of the Case Management Society of America (CMSA) and chair of the organization’s Public Policy Committee, she worked to gain recognition for case management particularly among lawmakers and leadership in the healthcare field.

“People across the entire healthcare spectrum are recognizing care coordination as a valuable service that can help provide better care for patients and benefit the bottom line at the same time,” says Leonard. She chairs the Clinical/Quality Committee of the Hudson Valley Care Coalition, a health home organization which also includes hospitals, community-based mental health agencies, federally qualified health centers, ambulatory care sites, and primary care providers, all with case managers who collaborate on care. (For details, see related article in this issue.)

In the past, hospital-based case managers were responsible for the episode of care but their responsibilities are no longer defined by the hospital walls. What happens after discharge can have a major effect on the hospital’s bottom line, Campagna says.

For instance, CMS estimates that in 2017, hospital penalties in the readmission reduction program will total $500 million, she adds. “When the readmission reduction program began in 2013, it was the first time hospitals were at risk for what happens after patients are discharged. In the readmission reduction program, penalties are based on a 30-day period — but with the bundled payment programs, the risk extends as long as 90 days,” she adds.

Hospitals across the country are closing their doors because of rising costs coupled with reduced reimbursement, says Carolyn Hamilton, MS, RN-BC, CDDS, CPHQ, corporate director of case management for DCH Health System, a three-hospital system headquartered in Tuscaloosa, AL.

“For hospitals to survive, we have to reduce the length of stay and cut down on overutilization of services. We can no longer leave what happens during that 30- or 90-day period after discharge to chance. We have to manage it closely,” she says.

Managing the resources of patients and hospitals has always been a part of the case manager’s role, but it’s becoming more important today, Hamilton says.

“Cost avoidance and controlling length of stay are what brought the case management role into the hospital in the first place. Now, with bundled payments, Medicare spending-per-beneficiary, and other initiatives, all the cost-related issues are extremely important,” Hamilton says.

In an effort to keep up with the changes in reimbursement, some organizations have created new care coordination roles to manage patients throughout the continuum, Hopkins says.

Instead of just adding new roles and titles, hospital administrators need to think about creating the right role but that hasn’t happened in many cases, Hopkins says.

“There has been a lot of talk about the role of case management and about coordination of care, but as a discipline, case management has not evolved and become as proficient in coordination of care as it needs to be. Case managers need to develop skills to better impact a changing healthcare environment, and that means looking beyond day-to-day care coordination and getting patients ready for discharge,” she says.

As hospitals assume more risk for patient outcomes after discharge, hospital leadership should re-evaluate the case management role and the people who fill it, Hopkins adds.

“Hospital leadership has to recognize that RN case managers are going to have to look beyond the walls of the hospital. They need to define the new role and determine what kind of caseload someone in that role can manage,” she says.

Hopkins advocates splitting the utilization review role from case management, freeing case managers to concentrate on progression of care. “What’s left is care coordination and discharge planning and, in today’s world, a big piece of the role should be transition of care. Case managers need to learn how to oversee a population well into post-acute care or as long as 90 days out if they are in a bundled payment arrangement,” she says.

Case management has taken a lot of different directions and roles, but the function is basically the same: to move patients through the continuum of care in the most clinically and financially appropriate ways, says BK Kizziar, RN-BC, CCM, owner of BK & Associates, a Southlake, TX, case management consulting firm.

“However, in an attempt to enhance the quality of care, we have cut the care process into little pieces. Instead of having one person responsible for fewer patients, we typically have more people who are responsible for more patients,” Kizziar says.

There are licensed clinicians and lay people with various titles overseeing and coordinating some aspects of patient care throughout the continuum. Often, their roles overlap and they provide duplicate care, she says.

The increase in population health initiatives is leading to another new group of providers — dieticians, exercise physiologists, pharmacists, and others — whose work also must be coordinated, Campagna adds. The emphasis on population health is likely to increase as the number of people with chronic illnesses increases to an estimated 157 million by the year 2020, she adds.

After discharge, patients often are treated by multiple physicians who are not connected with each other and may give the patient inconsistent messages. This is where care coordinators can help by making sure all the physicians know what the others are doing.

“It’s never a good idea to leave coordination of care from different providers to the patient. There has to be somebody who is overseeing everything, and that is where board-certified case managers have expertise,” she says.