But incentives depend on reimbursement structure
Community case management is gaining favor among many hospitals, but according to Donna Zazworski, MS, RN, CCM, FAAN, managing partner of Case Management Solutions in Tucson, AZ, the incentive to implement a community case management program depends on the motivation of the payer, which is based mainly on the reimbursement mechanism in place.
"If you are in a market where there is a lot of capitation, there is greater incentive to have nurses out in the community performing community case management to prevent hospitalization," she says.
According to Zazworski, if the hospital is receiving a per-member per-month payment from the payer, its motivation is to keep patients out of acute care because it is receiving only a flat fee every month based on the membership they are contracted for.
For example, if an elderly population with congestive heart failure are regular admissions to the hospital, there is a powerful incentive to keep them out of the hospital because they can have a long length-of-stay if they are admitted, she says.
In those instances, she says a community case manager, in many cases a telephonic case manager, can help reduce hospitalization as well as emergency department visits. However, if the capitated agreement is not negotiated properly, the incentive for community case management may be nonexistent, she warns. Other community case management programs can be tied to clinics, Zazworski says. If there is no payer source, the incentive may be simply to help high-risk patients comply with their disease management such as diabetes or asthma, she adds.
Calculating return on investment for community case managers can be difficult, Zazworski says.
"It all depends on what your indicators are," she explains. For example, one hospital-based community case management program she implemented for congestive heart failure looked at how much it cost to have those patients in the hospital.
"We saw that we were probably close to $500,000 for a certain subset of patients with congestive heart failure who were under capitation," she reports. However, a pilot program showed that the hospital could reduce readmissions by 18% and first-week readmissions by 40%.
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