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The role of the hospital case manager has taken many twists and turns over the past two decades. Case management started out as a sectioned-off role of utilization review without any relationship to the direct care providers or interdisciplinary care team.
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In the newly revised Discharge Planning Interpretive Guidelines, the Centers for Medicare & Medicaid Services (CMS) includes what it calls "blue boxes" that advise hospitals on best practices in discharge planning and care transitions.
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Medicare requirements for issuing the Important Message from Medicare (IM) and the Hospital-Issued Notices of Noncoverage (HINNs) have been around so long that they sometimes get short shrift.
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When hospitals determine that the care patients are receiving or are about to receive will not be covered by Medicare because it is not medically necessary, not delivered in an appropriate setting, or is custodial in nature, the hospital should provide the patient with a Hospital-Issued Notice of Noncoverage (HINN) to inform them that they will be responsible for the bill if they choose to stay in the hospital.
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While studies show that most people come to the ED because of an urgent or emergent medical concern, some people wind up in an emergency setting because they are not plugged in to the kind of social or medical resources that could more appropriately meet their needs.
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Since Tufts Health Plan launched its integrated care management model for Tufts Medicare Preferred, its Medicare Advantage plan, the Watertown, MA, health plan has seen significant reductions in hospital admissions and readmissions.
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Keystone Mercy Health Plans Acute Care Transitions program, which embeds case managers in hospital emergency departments to work with patients who seek treatment or are hospitalized, reduced emergency department visits by 21% and hospital inpatient admissions by 32% over the course of a year among members who received interventions when compared to a control group.
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In todays climate of healthcare reform and with the growing emphasis on quality, there are more opportunities for case managers than ever before.
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EmblemHealths team approach to providing face-to-face care coordination after hospitalization resulted in a 31% reduction in the 30-day readmission rate for members who received the interventions when compared to a baseline group.
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As providers struggle with that small percentage of patients who consume the majority of healthcare dollars, theyre finding that having care coordinators who work face to face with patients often can help patients navigate the healthcare system and follow their treatment plan.
