Hospital Case Management – November 1, 2016

November 1, 2016

• New Role for Case Managers Opens Up with Payment Reform

  Somebody has to coordinate the post-discharge care now that hospitals are beginning to bear risk for what happens to patients after discharge, but inpatient case managers are already swamped and don’t have the time to do the job well, experts say.

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• Coordinating Transitions Requires Experience, Knowledge of Resources

  The role of transition coordinator may be a new one, but it will take an experienced case manager or social worker to handle it successfully.

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• Develop Criteria for Patients Referred to Complex Case Manager

  Don’t base referrals to the complex case manager strictly on the age of the patient or the diagnosis.

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• Communication is the Key to Ensuring a Successful Transition

  In the hospital setting, the inpatient case managers should communicate amongst themselves, with the patient and family, and the nurse navigator, who, in turn, communicates with patients and everybody involved with them after discharge.

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• Home Visits Help Reduce Readmissions for At-risk Medicare Patients

  Hallmark Healthcare’s Community-based Care Transitions project created the position for transition facilitators who visit at-risk patients in their homes and achieved significant decreases in readmissions.

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• Respite Care for Homeless After Discharge Cuts Avoidable Days, Readmissions

  An $800,000 investment in a respite program that provides a place for homeless patients to recuperate after discharge has saved participating hospitals in Santa Rosa, CA, $17 million in the first three years.

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• Technology is Great, but Use it With Caution

  Case managers now have access to technology that makes their jobs easier, but should be careful to preserve patient confidentiality, experts say.

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