Case Management

Case managers must evolve as healthcare changes

Case Management Insider, February 3, 2015

Last year was a big one in healthcare. From tangles with the Ebola virus that revealed weaknesses in the American healthcare system to the ever-changing 2-midnight rule requirements, case managers had a lot to stay on top of in 2014.

Healthcare changed a lot last year. The Commonwealth Fund, a private New York City-based foundation that aims to promote health system improvements recently came up with its list of noteworthy healthcare-related items in a recent blog post.
Authors David Blumenthal, MD, and David Squires, listed a number of changes from the drop in the uninsured rate, (from 20% to 15%), to Ebola and the rise in the number of Accountable Care Organizations. “The percent of private health insurance payments that are ‘value based’ jumped from 11% to 40% in the past year, according to one study,” said Blumenthal and Squires.
But don’t expect the changes to stop in 2015. June Stark, RN, BSN, MEd, director of care coordination at St. Elizabeth's Medical Center-Steward Healthcare in Boston, says case managers should have a few on their radar for the coming year.
Healthcare reform changes will continue, and case management may change as a result, she says. Stark advises case managers to be on the lookout for changes, including:
  • Readmission additions. This year, the Medicare Readmission Avoidance will expand to include chronic obstructive pulmonary disease, plus total hip and knee, says Stark. These will join past diagnoses, including myocardial infraction, congestive heart failure, and pneumonia. “If you haven’t already, collaborate with physician and nursing partners to develop plans to reduce readmission when appropriate,” Stark says.
  • Tweaking transitions. The government will continue to focus on improving transitions for patients from one level of care to another. Case managers should follow suit by continuing to build knowledge and expertise in transitions of care, which assists in stabilizing the chronically-ill in the community, Stark says.
Remember changes to the 2-midnight rule went into effect in January. As of January 1, 2015, CMS says physicians only need to certify long-stay and outlier cases, which they must include in the chart by the 20th day of the patient’s hospital stay, Stark says. This may or may not be a big change for your organization, depending on how you handled the requirement initially. If your hospital created a certification form for inpatient admissions, the change may cut down on the workload. However, some organizations simply expanded the utilization review specialist’s review process to meet the requirement. This called on organizations to incorporate the elements of a qualified inpatient admission in addition to the medical necessity criteria. If this is the case, the change might not be as noticeable.
There will likely be other regulations and revisions to consider as the year progresses, so be certain to regularly check government websites for updates. 

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