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As reimbursement adjustments under the Centers for Medicare & Medicaid Services' (CMS) Value-based Purchasing (VBP) Program start to kick in this October 1, it's more important than ever for case managers to be pay attention to overall quality improvement and not just concentrate on particular patients or conditions, says Danielle Lloyd, MPH, vice president for policy development and analysis for the Premier healthcare alliance, with headquarters in Charlotte, NC.
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For years, the Centers for Medicare & Medicaid Services (CMS) state operations manual has had guidelines for surveyors to assess issues related to patient safety at hospitals. But there is such a wide range in size and scope of hospitals, says Marilyn Dahl, CMS director of the division of acute care services, that the organization decided it would be a good idea to create some sort of prompt for surveyors to use.
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Since Fallon Community Health Plan in Worcester, MA, began integrating medical case management and mental health case management, members in the health plan's Medicaid HMO with medical issues have experienced fewer inpatient days and emergency department visits and those in behavioral health have less need for unplanned medical care, says Dena Miller, RN, MSN, vice president of clinical innovation and implementation for the health plan.
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To keep a lid on costs, health care policy experts recognize that hospitals need to find more effective ways to manage transitions. The care coordination piece can be particularly problematic in the fast-paced ED setting, and yet it can make a big difference in determining whether a patient receives appropriate follow-up after an acute event and whether he or she is back in the ED within days or weeks with another acute exacerbation of the same issue.
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A collaborative approach in which primary care physicians and nurse case managers work with patients with depression has resulted in a 50% improvement of scores on a depression questionnaire among patients who were part of a pilot project at UC Davis Family Medicine in Sacramento.
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As the National Committee for Quality Assurance hopes that all-cause readmission rate reporting by health plans will assist in creating more consideration of patient care across the continuum, the National Quality Forum (NQF) hopes a new measurement framework for multiple chronic conditions will likewise help improve care in and out of the hospital.
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Recognizing that medical problems and behavioral health issues are often intertwined, payers and providers are coordinating behavioral health and medical health case management.
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In the past, if a member of Capital District Physicians' Health Plan (CDPHP) in Albany, NY, was hospitalized for a suicide attempt and ended up in the intensive care unit, or was hospitalized with a medical problem and diagnosed with a behavioral health issue as well, the medical case manager would give him or her a referral to a toll-free number for an out-of-state vendor that provided behavioral health management for the health plan.
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Getting an entire staff of physicians, nurses, and techs to do things differently is never easy, but you can clear away hurdles by giving them the ability to formulate some of their own solutions.
