By Melinda Young


A health system’s focus on revamping its care coordination led to a reduction in some 30-day readmissions, as well as other benefits.

The program, which focused on streamlining operations and improving quality, showed a 3.6% decrease in post-acute utilization.

The health system started the change by re-evaluating its staffing approach and looking for ways to improve case manager efficiency.

Discharge planning and utilization review roles were separated in the new model.

A team-based approach to care coordination can work well as hospitals look for ways to streamline operations and improve quality.

One such program at The Valley Hospital in Ridgewood, NJ, has racked up positive outcomes, including:

• Reducing Medicare 30-day readmissions by 1.2%;

• Lowering sub-acute rehab utilization by 3.25%;

• Decreasing post-acute utilization by 3.6%;

• A 5% increase in the overall care transitions domain on patient experience surveys.

To streamline operations, the hospital re-evaluated the staffing approach, and looked for ways to improve the efficiency of each case manager and social worker, says Margaret Pogorelec, DNP, RN, CEN, NE-BC, director of care coordination at The Valley Hospital.

For example, The Valley Hospital analyzed its unit-based approach to case management and found that although each case manager’s caseload was even, the acuity levels were not. The hospital also used a standard approach to case management, with case managers on each unit handling both commercial utilization review (UR) and discharge planning. Social workers also handled discharge planning. One UR team focused solely on Medicare and did not handle discharge planning, she says. The new model separated the discharge planning and utilization review roles. (See story on how to improve case management and care continuum efficiency in this issue.)

“We have a case manager and social worker on each of the units. We also have transition coordination and the utilization review nurse,” she explains. “There are one or two of them, depending on the unit. For every two teams, there is a complex care coordinator.”

A major challenge in separating utilization review and discharge planning was finding staff to fit the new jobs. Employees could choose which one they wanted, and this did not result in a perfect fit — at least at first, Pogorelec says. “The discharge planning piece was a little easier, and the utilization review piece was more challenging,” she adds.

With staff turnover and hiring focused on applicants with the specific skills needed, this worked out, she adds. The new model includes various levels of support, but it reduced duplication when compared with the old model.

“We had tons of duplication — between the case manager and the social worker, and between the utilization review, case management, and home care case management,” Pogorelec says.

Previously, the case manager would prepare patients for discharge and handoff to home care coordination, although the work was already completed. The additional effort by home care staff was duplicative, she explains. “We put everyone into a figurative bag and tried to eliminate any duplicity so we could streamline the care,” Pogorelec says.

Another change involved eliminating the role of fill-in case managers, who floated from one unit to another, going wherever they were needed. “We had a lot of these [floating] case managers built into the model, but there were complaints about the quality of their work,” Pogorelec says. “It wasn’t a good model for us because the whole idea of our program is that everyone has a specific job.”

The new model includes built-in workflow flexibility because case managers on unit A can help case managers on unit B if that unit needs additional help. There are people, including Pogorelec, who fill in for people on vacation.

Another aspect involves the hospital’s new population health department, which was launched in 2016 to support a defined population of a Medicare accountable care organization (ACO), says Toni Modak, BSN, ICM, PCC, director of population health at The Valley Hospital. The population health department also has payer contracts with private payers and manages tens of thousands of lives, she adds.

“We needed an infrastructure to support the ACO,” Modak says. “We looked at the care delivery model where we’re delivering care to our patients, and we put together a team of telephone case managers, who follow our patients across the continuum.”

The goal was to follow patients’ journeys and closing gaps in care. “We make sure they don’t fall beneath the cracks, and really work closely with physician practices,” Modak says. “We’re there as a layer of support for physician practices.”

In addition to the population health nurses, the organization created a role for population health staff navigators who are embedded in post-acute facilities.