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A proactive approach to engage at-risk members before they have an adverse medical event is paying off for CareFirst BlueCross and Blue Shield, a Baltimore-based health plan.
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A study conducted at Good Samaritan Hospital in Dayton, OH, has determined that denial rates are lower when case managers collaborate with physicians to determine patients' admission status.
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The assessment tool used by federal government programs to measure whether a community health center is functioning as a "medical home" was developed by the nonprofit National Committee for Quality Assurance (NCQA).
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As part of its efforts to reduce readmissions, WellStar Health System, based in suburban Atlanta, is meeting with post-acute providers to collaborate on ways to make transitions between levels of care smoother. It is piloting a program in which a transition coach works with heart failure patients in the hospital and follows them for four weeks following discharge.
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One of the ways busy EDs are attempting to manage long wait times is by enabling patients who don't need immediate care to make an appointment to be seen in the ED one or two hours in advance.
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When St. Anthony's Hospital and Pinellas Point Nursing and Rehabilitation, both located in St. Petersburg, FL, collaborated on a project to reduce heart failure readmissions, the team determined that many readmissions were for sepsis. They embarked on a project that eliminated sepsis as a reason for readmission in just six months.
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Since the Presbyterian Healthcare Services in Albuquerque, NM, started its emergency department navigation program, targeting patients who seek treatment for minor ailments, 11,600 patients have been navigated to other levels of care. Only about 5% of them have returned to the emergency department with non-emergent conditions or illnesses.
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In this month's issue of Case Management Insider, we will continue our discussion on case management roles, functions, and models, with more information on today's best practice models. We will explore the advantages of each model and minimum staffing ratios for each.
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With increasing scrutiny on medical necessity and cuts in reimbursement, along with a growing emphasis on care coordination and transitions in care, case management's position as a major player in the hospital should be assured. But that's not always the case.
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Hospital systems and care transition teams should take a close look at their practices regarding patients for substance use problems, with a goal of improving screening and discharge planning to prevent readmission of these patients, experts say.
