Executive Summary
In recent years, case management has been recognized as a key in improving healthcare quality and reducing costs, but while hospitals are giving case managers more responsibilities, many administrators are not approving an increase in staff to handle the extra work.
- Case managers can help their hospital succeed with the Centers for Medicare & Medicaid Services’ Value-based Purchasing program, the readmission reduction program, and bundled payments.
- Case management directors should make sure the hospital’s senior leadership understands the roles and responsibilities of case managers and how their interventions can affect outcomes and the bottom line.
- The number of caseloads depends on the case management model, the responsibilities of case managers, and whether they have assistants or case management extenders who can take over some tasks and allow the licensed staff to work at the top of their licenses.
- Don’t let technology replace communication and patient-centered interactions.
Case managers cheered when the Affordable Care Act and other initiatives by government and commercial insurers mentioned the need for care coordination over and over. But as more and more responsibilities are being heaped on case managers, all that recognition may have been a double-edged sword, experts say.
“We keep saying it is case management’s day, and the increasing emphasis on care coordination and managing transitions means it truly is our day. But in many hospitals, the administration doesn’t understand the case management department doesn’t have enough staff, or the staff they have aren’t doing the right things,” says Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts.
Hospital administrators have a concept of the value of case management based on the past, but many are not connecting the dots between the new initiatives from the Centers for Medicare & Medicaid Services (CMS) and other payers, what case managers can do to help their hospital comply and succeed, and the need for additional staff to handle the additional responsibilities, Cesta says.
Even with the pressure being put on case management, it’s still an exciting time to be a case manager, says Cheri Lattimer, RN, BSN, executive director of the Case Management Society of America (CMSA).
“As healthcare evolves, case management is playing a definite role. I believe that we will see significant changes in clinical outcomes and the ability to better coordinate care. We’re getting there, but we still have a long way to go,” Lattimer says.
As CMS and other payers move to new reimbursement models and requirements, hospitals are going to have to change in order to stay in business, and case managers are a key to their success, says BK Kizziar, RN-BC, CCM, owner of BK & Associates, a Southlake, TX, case management consulting firm.
CMS is quickly moving toward reimbursing hospitals for quality, not quantity, and testing initiatives that put hospitals at risk for patient outcomes, she adds. The most recent initiative, the Comprehensive Care for Joint Replacement bundled payment pilot project, announced in June, requires hospitals in 75 geographic areas to participate in the five-year project and bear risk for cost of patient care from the time of surgery until 90 days after discharge.
The voluntary Bundled Payment for Care Improvement pilot project has been underway since 2013. In addition, hospital reimbursement is affected by a variety of CMS programs, including the readmission reduction program and Value-Based Purchasing.
“Today’s hospital case managers are under stress from increasing payer regulations and requirements, decreases in reimbursement, and the responsibility of ensuring that physicians document fully,” says Karen Zander, RN, MS, CMAC, FAAN, president and co-owner of the Center for Case Management.
Bundled payments are not yet having a big effect on case managers because only a minority of patients are part of a bundled payment initiative, but CMS has announced intentions to continue expanding the program, she adds.
“Healthcare systems and payer requirements are becoming increasingly complex and case managers are required to know more and manage more,” says Charlotte Sortedahl, DNP, MPH, RN, CCM, assistant professor in the department of nursing, University of Wisconsin Eau Claire, and newly elected secretary of the Commission for Case Management Certification.
All of the changes in healthcare and reimbursement put case managers in an excellent position, she adds. “Case managers are well positioned to help hospitals comply with the new rules and regulations, as well as preventing readmissions and helping their hospitals succeed under value-based payments and bundled payment arrangements,” Sortedahl says.
With all the new initiatives, CMS and other payers are moving toward a goal of improving patient outcomes and patient satisfaction while lowering the cost of care, Lattimer points out.
“Patient models are focused on good outcomes and payers are no longer focused on payment for processes but are emphasizing value, improving outcomes and satisfaction, and lowering costs,” she says.
Recently, CMS has accelerated the pace at which it implements new initiatives and requirements, Cesta says. “In the past, they went much more slowly in issuing new models of reimbursement and requirements for hospitals. They used to put out an idea and think about it and collect comments for years before they ever made a change. Now they announce potential changes and institute them quickly,” she says.
When CMS required hospitals to track and report Core Measures, hospitals added staff to their quality departments, Cesta says. “The penalties that are instituted now are much bigger than penalties for not complying with the Core Measures requirements, and they’re only going to increase,” she says.
Case managers are the missing link for hospitals’ success in the new world of reimbursement, Cesta says. “No other department focuses on patient transitions, but the resources are not behind it. Case managers don’t have the resources to do their job effectively and they are burning out,” she adds.
Caseloads have dropped in the last five years, but the powers that be in the hospital still don’t understand how time consuming it is to do the job effectively, Cesta says.
“Discharge planning doesn’t sound very complicated, but while creating a plan for one patient may take just five minutes, another may take five hours, and another five days. Hospital administrators don’t understand how the work has accelerated and become more complex,” Cesta says.
But things may be looking up, she adds.
“Since almost every major change that affects case management has been attached to some kind of reimbursement, it appears that things are starting to change for case managers because of the financial implications,” Cesta says.
Most hospitals are looking at the possibility of following patients beyond the hospital walls and to do so in the most cost-effective way, Kizziar says.
“Everybody is scrambling to maximize reimbursement. Additional staff means added benefits for the hospital, but it’s a real challenge to determine return on investment,” Kizziar says.
Before asking for more staff, case management directors should ensure that their hospital’s senior leadership understands the roles and functions of case management and how their interventions can impact outcomes. “Every hospital has to focus on performance measures, readmission penalties, patient satisfaction, and other measures as mandated by CMS,” Lattimer says.
It requires data to make the case for additional staff, Lattimer says. If you don’t have performance data from care coordination efforts from your own hospital, research the results from other hospitals and accountable care organizations, she says.
The National Transitions of Care Coalition (NTOCC) has an extensive compendium library that includes case management models and tangible savings data, she adds. (For more information, see www.ntocc.org/Toolbox.)
Chief financial officers often ask case managers for a return on investment report before they will talk about adding new staff, Zander says.
“They want to know what the costs for new staff compared to what will be saved or how much revenue will be increased by adding new staff. Before asking for new staff, case management directors need to determine a return on investment for every task the department undertakes,” Zander says.
“It is going to have to get to the point where case management is recognized as being as necessary as other departments. The administration doesn’t ask for return on investment for nursing or pharmacy,” Cesta says.
Cesta recommends that case management directors start their requests for new staff by educating the administration on the Conditions of Participation. “Many administrators are not familiar with the Conditions of Participation and that’s a good place to start. Point out that utilization management and discharge planning are CMS requirements,” she says.
Then get into some of the other financial aspects and point out that nobody else is going to help the hospital meet the requirements from CMS and other payers, Cesta says.
“Aside from the fact that coordinating care for patients and ensuring a safe transition is the right thing to do, hospitals have to adhere to the law and comply with the Conditions of Participation,” Cesta says.
While hospitals are giving case managers more responsibilities, many administrators are not approving an increase in staff to handle the extra work.
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