Hospital Case Management: Retreating Multidisciplinary Strands For Adaptable Care

Hospital Case Management: Retreating Multidisciplinary Strands For Adaptable Care

Case management, being a paramount procedure, is carried throughout the health care system for improving quality and amortizing costs. Case management structure primarily includes nurses and social workers, but with the advancement of the treatment, other professional disciplines join the practice that assists patients and their caregivers to sail through the complex healthcare composure. Today, a case manager role involves being multifaceted and decisive due to the expansion of the healthcare landscape, discharge planning and transition from an episode of care to the community to reduce readmissions and improve the patient experience. Financials of care need to be inscribed as insurers, and other government agencies do not pay for attention which is inefficient, uncherished quality and provides a positive patient experience while promoting patient's safety.

Signed in March 2010 by President Obama, the patient Accountability and Affordable Act (ACA) to open up access cost-efficient, polished care for all the Americans. Most notably, the legislation fixed a National Strategy for Quality Improvement in Healthcare, strengthened patient-centered, friendly and safe care for the significant improvement of the nation's health. The necessity to locate conciliation that promotes health while recognizing diverse characters of (behavioral, social and environmental) of health care is necessary to expedite a reduction in cost for quality service provided to all citizens of America.  Measurable quality services concentrated on optimal patient outcomes and patient experience will count for a longer term. Recognizing the importance and promoting incorporation of the Case Manager role is essential in these endeavors.

Elements of Requisite Bundle Payments-

Bundled Payments for Care Improvement (BPCI) vitality was CMS' first attempt to understanding how bundled payments might work which was initiated as a voluntary program. Hospitals can choose from the different payment models available, each with distinct levels of financial risk. The four different payment models are as follows:

1. Retrospective Acute Care Hospital Stay Only

2. Post-Acute Care Plus Retrospective Acute Care Hospital Stay 

3. Retrospective Post-Acute Care Only

4.  Acute Care Hospital Stay Only

Following the end of a performance year, based on claims submitted by March 1, payments are contemplative each year. There are some risks affiliated with the bundled payment model which, if not well managed, can have an adverse financial effect on the hospital.  These include the following:

  • Repetitive admissions
  • Paying others out of the bundle as many billing systems do not administer bundled payment contracts
  • Quality metric payments are not accosted

Managing Acute Care Case-

According to Beverly Cunningham MS, RN, ACM, the solution to getting the patient status right is to have case managers in the right places to review the cases of patients coming to the hospitals. Establishing the case manager to evaluate surgical orders ahead of work and time with the physicians to get the patient's status and orders right is one solution to ensure that the admitted surgical patients meet the inpatient criteria.

In smaller hospitals, the emergency department case manager could review patients who are being directly admitted. In larger hospital systems, case managers function in the transfer center. To be efficient in today's healthcare environment, case managers need to be competent and acquainted with rules and regulations issued by CMS and other payers, and clinical knowledge to interrogate with the physician.

Incorporating case management across the perpetuity requires silos removal separating acute care and community-based case management. These gaps in case services are directly related to the estrangement in ways hospitals are reimbursed. Hospitals are looking for reimbursement programs like bundled payments, accountable care models, and community- based programs.

Coordinating Care With Value-Based Reimbursement-

The shift to reimbursement prospect means case management departments must now provide an infrastructure for well- managed patient care, which includes ongoing care provided by the community to support discharged patients. It requires case managers to develop hard-wired processes that produce a structure for managing high-risk patients and effective handoff communication.

Case Managers synchronously plan for transitions of care, discharge and often post-release follow up. Case Managers coordinate with the patient and their family, physicians, funding sources that provide services which the patients might need, such as medical equipment or rehabilitation facilities. This coordination helps hospital case managers ensure that both hospital outcomes and optimal patient including quality care, coherent resource utilization, and reimbursement for services are met methodically. 

Therefore it can be comprehended easily that hospital case management is a deceitful convention, which consists primarily of Nurse and Social Work professionals working in cooperation with physicians and other members of the healthcare team.