Centers for Medicare and Medicaid Services (CMS)
RSSArticles
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Care Coordination and Communication Needed Between Transplant Providers and Primary Care
Cirrhosis affects a small percentage of the U.S. population. But it is a highly complex disease that leads to high hospital readmission rates and a higher cost per patient than found in heart failure and COPD. Investigators found care coordination and efficient communication between providers can optimize care. Telehealth can help patients, particularly for return visits.
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International Discharges Create Chaos and Inspire Creativity for Case Managers
Case managers and discharge planners in every state sometimes encounter the most challenging and frustrating of cases: the international discharge. Hospital Case Management asked Judith R. Sands, RN, MSL, BSN, CPHRM, CPHQ, CCM, ARM, a clinical consultant and author of Home Hospice Navigation: The Caregiver’s Guide, to answer a few questions about best practices in handling these unique care transition cases.
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Stroke Patient Navigator Prevents 30-Day Readmissions
A stroke nurse navigator team can prevent 30-day readmissions in stroke patients treated with thrombolysis, investigators found. A health system’s 30-day readmission rate was 13.6% before it began to use a stroke nurse navigator. The rate declined to 6.9%. Patients with the stroke nurse implementation were 67.6% less likely to be readmitted within 30 days compared to patients without the navigator.
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How Case Managers Can Help Victims of Trafficking
Case managers can learn skills and tactics for helping patients who have been trafficked. For example, investigators used an online training module to educate ED staff about human trafficking. Participants reported more confidence in identifying a possible human trafficking victim, noting they were more likely to screen patients for human trafficking.
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Screening and Documenting Cases of Human Trafficking Are Important, But Carry Risks
Human trafficking is a critical issue from a public health perspective. It has lasting psychological and physical effects on victims. There is too little information about how prevalent human trafficking is in the United States and how often the victims are seen in healthcare settings. Case managers, hospitals, and ambulatory providers could improve the data by documenting suspected or confirmed human trafficking cases via Z codes.
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Case Managers Could Use Z Codes More for Patient Care and QI
Case managers, providers, and health systems underuse ICD-10 Z codes eight years after they were introduced. These codes could provide a wealth of data to researchers and case management quality improvement projects. They still hold promise to be a way for providers to collect reimbursement for their work to help patients with their social determinants of health.
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Nurse Care Coordinators Are Valuable in Federally Qualified Health Centers
A Federally Qualified Health Center that invested in a registered nurse care coordination program in a primary care setting found the position provided a valuable service and was cost-effective.
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How to Fight Denials
Case managers do not have to settle for denials. In fact, they can use their skills to overturn denials. There are certain tactics that can help in this process, and some case management professionals even specialize in this.
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Hispanic Patients with Diabetes Need Better Care Transition Models
About one in 10 Americans are diagnosed with diabetes, and the Hispanic/Latino population is disproportionately affected. Their risk is higher — and their outcomes are worse — than the white, non-Hispanic population. Researchers designed a transition of care model and pilot to see if they could improve outcomes.
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Care Transitions Through ACHIEVE Study Score Points with Patients
Care transitions across organizations and the community require better collaboration and communication among providers and social service organizations, according to recent research. Patients benefited from improved collaboration. They reported feeling better supported and cared for by providers involved in a care transition project.