Case managers can’t just keep doing the same old thing when bundled payments arrangements begin. Because the hospital is taking a financial risk by participating, case managers must ensure patients receive everything they need in a timely manner and move through the continuum quickly and safely.
One of the biggest obstacles to cost-effective care is the disconnect between the various roles involved in caring for patients, says Donna Hopkins, MS, RN, CMAC, a case management consultant based in Boerne, TX.
Hospitals have added personnel across the continuum to ensure compliance with new CMS rules, Hopkins points out. “As a result, the leaders of one department don’t always know what the staff in another department is doing, and they may duplicate their efforts or omit a crucial task because they think staff in the other department is doing it,” she adds.
She relates a personal experience when the case manager didn’t know the patient navigator. Both of them were arranging follow-up appointments. “They should be working together to coordinate care, but this is what can happen when there are different senior leaders overseeing care coordination and each has a different agenda,” she says.
When there are multiple roles responsible for care coordination and follow-up, they should be supervised by one leader, Hopkins advises. “This helps ensure that the various staff members work in a coordinated effort,” she adds. She suggests that one central role monitor care over the entire continuum from the doctor’s office through the end of post-acute care.
Hopkins and other consultants offer more tips for surviving under bundled payments:
“If the leaders of one department, provider, or service don’t know what the other is doing, they may duplicate or omit services,” she says. “We have learned that having one electronic medical record is not the solution. There needs to be a centralized care coordination role by service line to scrutinize the patient care over the entire continuum, from the doctor’s office through post-acute care,” she says.
The bundled payments program creates an opportunity for physicians in the community, other post-acute providers, and hospitals to work together to deliver high-quality care, says John Wagner, associate director at Berkeley Research Group.
With bundled payments covering the episode of care from admission to 90 days after discharge, the at-risk provider — in most cases, the hospital — must provide oversight after discharge, says Ken Steele, principal with ECG Management Consultants.
He recommends that case managers collaborate with their counterparts at patients’ primary care providers and the offices of whatever specialists they are seeing after discharge to make sure everyone is on the same page. Work with the case managers at skilled nursing facilities, home health agencies, and other post-acute providers, he adds.
Connect patients with the care managers that will coordinate their care after discharge, such as those at an insurance company, physician practice, accountable care organization, or a community organization. “Make sure everyone who will touch the patient — either in person or virtually — after discharge knows the plan of care and communicates across the continuum,” says Brian Pisarsky, RN, MHA, ACM, director at KPMG Healthcare Solutions.
“Remember that the cost of post-acute care is part of the bundle, and make sure you guide patients in their choice of the most appropriate post-acute providers,” Pisarsky adds.
You still have to give patients a choice, but you can mention the providers that have produced good outcomes, he says.
Case managers should give their recommendations for post-acute care, but still give patients a choice, Steele says. “For some patients, it’s their first experience with post-acute care and they may not be able to differentiate between providers. Case managers can guide them in the decision-making process,” Steele says.
Meet patients with planned admissions before they are admitted to assess their support systems and living situations and to give patients an idea of the normal course of care when they’re in the hospital, their expected length of stay, and what they’ll need to do after discharge, Pisarsky says. Take the opportunity to help patients choose their post-acute provider, if needed, before they come into the hospital.
“There are a lot of things that can be done ahead of time during the preadmission visit,” Pisarsky says. For instance, joint replacement patients can get the prescription for a walker during preadmission testing, he adds. Meet with the family before a planned surgery and ensure they understand the pathway for the patient care process. Explain the roles of the case manager, staff nurse, physician, and any other clinician who will see the patient.
CMS is going to base its price target for the bundled payments project partly on risk-adjusted data, says Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Services, a Shawnee, OK-based healthcare consulting firm. Hospitals must make sure Hierarchical Condition Category diagnoses are adequately documented so they can be correctly coded, she adds.
“Even though the diagnoses don’t impact the DRG payment, they do impact the calculation of severity of illness and that plays a big role in determining whether the hospital achieves success or not. Failure to get credit for the complexity of their patients can sink a hospital’s bundled payment boat,” she adds.