Hospital case management : the monthly update on hospital-based care planning and critical paths
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The fact that the CMS is extending its three-year voluntary Bundled Payments for Care Improving pilot and has launched the mandatory bundled payment project, Comprehensive Care for Joint Replacement in 7 markets leads experts to conclude that bundled payments are here to stay and will be expanded. Bundled payments mean case managers need to manage the length of stay and choice of post-acute options more closely than ever before and make sure that patients receive the most cost-effective and efficient care to meet their individual needs. Even if their hospital isn't part of a bundled payment program, case managers should prepare for the future by cementing relationships with post-acute providers and analyzing the variability in cost of care and patient outcomes and identifying opportunities for improvement. Relationships with post-acute providers are critical and should go beyond getting to know the staff, and include sharing patient data.
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The Centers for Medicare & Medicaid Services' (CMS') mandatory bundled payment pilot project makes clear that the agency intends to reform Medicare reimbursement. Hospitals in 75 geographic areas are required to participate in a five-year pilot project that puts them at risk for the cost of hip and knee replacements from the time of surgery until 90 days after discharge. ⋯ Even if they won't be part of a bundled payments arrangement, case managers need to shift their thinking to prepare for the future of reimbursement by developing close working relationships with post-acute providers, knowing the services and quality delivered by post-acute providers, and being aware of the costs for the entire episode of care. Case managers will not be able to handle all the responsibilities necessary in a bundled payment arrangement if they have large caseloads.
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The Centers for Medicare & Medicaid Services' (CMS') 2016 proposed rule for the Inpatient Prospective Payment System (IPPS) continues to shift the Medicare program to reimbursing providers based on quality metrics. CMS continues to raise the bar for hospitals by adding new metrics to Value-Based Purchasing, the Hospital Readmission Reduction program, and the Hospital-Acquired Condition Reduction program. Case managers should continue to educate physicians on the effect that the quality metrics have on the hospital bottom line and work with the multidisciplinary team to ensure that patients get the care they need in a timely manner and that documentation reflects the patient's condition and services received. In the proposed rule, CMS announced that it is considering feedback it has received on the two-midnight rule and will include a further discussion of the issue in the Outpatient Prospective Payment System final rule.
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This month we have begun reviewing the top mistakes hospitals make within their case management department's infrastructure. As discussed, the biggest mistake is to not clearly and prospectively define the roles of the RN case manager and the social worker to optimize each discipline's skill sets. Associated with this mistake is to have inadequate patient ratios assigned to each discipline. ⋯ In the end, this logic is penny-wise and pound foolish. We do both disciplines a disservice when we don't apply their skill sets adequately and don't have each group functioning at the "top of their license!" Next month, we will continue to discuss the top mistakes hospitals make in their acute care management departments' design. We will discuss the use of clerical support staff, assessments, and days of coverage.