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When a five-year, federally funded demonstration project began in New York, the goals were lofty: reduce preventable readmissions by 25% or more. NYU Langone Health achieved this goal through identifying frequent users and working with them through a targeted case management approach.
Nearly a decade ago, Maryland experimented with a global budget payment model for rural hospitals. The plan was to give them a set amount of money, called Total Patient Revenue, to improve their efficiency. But it did not quite work out. ED visits dropped 12%, and non-ED admissions declined 23%. But there was little incentive for the hospitals to collaborate with community providers to improve patients’ health. Instead, the hospitals just reduced overall services.
West Virginia University's diabetes care program helped patients lower their A1c levels from an average of 10.25 to an average of 8.7 within three to six months. Even at 18-month follow-ups, 86% of patients recorded lower A1c levels than they did in the beginning, and one-third of patients registered A1c levels below 8. The team-based diabetes care program started as a quality improvement initiative.
Children living with chronic illness often struggle with their treatment regimen. Depression and anxiety may be involved, as the child likely cannot cope. But that is just one component of the noncompliance picture. Psychological and medical trauma, as well as family issues, may be involved.
After acute care, a stroke patient’s discharge plan should include an inpatient rehabilitation facility (IRF) when they meet specific medical criteria, according to the 2016 American Heart Association/American Stroke Association guidelines. Stroke also tops the CMS 13 list, which designates 13 medical conditions that 60% of an IRF’s patients must have for the IRF to qualify. IRFs provide hospital-level care to stroke patients who need intensive, interdisciplinary rehabilitation care provided under the direct supervision of a physician.
This month, we will discuss principles related to ethics and how they affect one’s role as an RN case manager or a social worker. These principles include patient advocacy, which applies to all the roles and functions that case managers perform.
Financial Disclosure: Author Melinda Young, Author Jeanie Davis, Editor Jill Drachenberg, Editor Jonathan Springston, Editorial Group Manager Leslie Coplin, and Nurse Planner Toni Cesta, PhD, RN, FAAN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.
