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(Editor's note: This is a multi-part series where we will explore the most common roles, functions, models, and caseloads in the hospital case management field.)
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Key components of the initiatives include forging an alliance with post-acute providers, transition coaching for at-risk patients during the hospital stay and after discharge, and teaching patients to use their personal health record to track their care and list questions for providers, according to Tammy Cole-Poklewski, RN, MS, director of quality, patient safety, and care management at the 142-bed facility.
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After Charleston (WV) Area Medical Center began a readmission reduction program, readmission rates for a group of targeted heart failure patients was reduced by 50%.
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In response to comments from healthcare professionals, the Centers for Medicare and Medicaid Services (CMS) made significant changes to the final rule for the creation of accountable care organizations (ACOs), which encourage providers to better coordinate care across all settings.
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When it's typical for patients to wait four hours or more to see an emergency physician, and your leave-without-being-seen (LWBS) rate is pushing 10%, you know it's time to rethink the whole process.
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A year after Saint Joseph-London Hospital in London, KY, began a heart failure readmissions program, 30-day readmissions dropped from 27.7% to 15.9%. A similar program for patients admitted for acute myocardial infarctions (AMI) reduced the readmissions rate from 23% to 10% in a short time.
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When the Inpatient Prospective Payment System (IPPS) final rule for 2012 was issued, the Centers for Medicare and Medicaid Services (CMS) stated that its goal is to encourage hospitals to provide higher quality of care at a lower cost and to promote greater efficiencies across all care settings and throughout the entire health system.
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Most of the items in in the box "Characteristics and Core Competencies of Potential Candidates" (below) are inherent and/or learned over time.
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Your job descriptions should clearly define the minimum amount of education that you require for the role of case manager or social worker.
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Orientation should be geared to the experiential level of the new staff. The novice case manager will require a different orientation than the experienced case manager. You will need to determine this based on an assessment of the new staff member.
