Hospital Case Management – February 1, 2023

Case Management Leaders Advocate for Improved SDOH Assessments

Improving social determinants of health assessments will help the healthcare industry evolve and improve medical care and efficiency. Case management leaders should collect data to show hospital leaders how their work with social determinants can help a health system meet its goals.

How Case Managers Can Improve SDOH Assessments

Case managers can use several different tactics to improve their assessments of social determinants of health. These may require extra time, but they can yield big rewards in terms of patients’ health and preventing readmissions.

Many Safety Net, Rural Hospitals Do Not Properly Address Social Needs

Safety net hospitals, critical care hospitals, and rural hospitals often do less than needed to address the social determinants of health of their vulnerable populations, particularly during the COVID-19 pandemic, new research shows.

Study Reveals Positive Benefits of COPD Transition Bundle

A study of a care transition bundle that included a care coordinator revealed COPD patients in the bundle cohort were less likely to be readmitted to the hospital within seven days and 30 days, but 90-day readmissions were unchanged.

Integrated Care Teams Should Include Social Workers

Integrated care teams sometimes lack a social worker, which can undermine the team’s work and success. It is a shortsighted tactic because social workers can help with case management and care coordination in a variety of ways, including intake assessment and behavioral interventions, according to recent research.

Better Care Communication Needed for Home Health

Researchers wanted to know if there is an association between home health and gaps in care coordination among providers. They found patients receiving home healthcare are sicker, experienced more functional dependencies, and reported more preventable drug-drug interactions. While home health was not associated with a difference in gaps of care coordination, it was associated with twice the risk of a preventable adverse outcome.

Effectively Intervening with Patients Facing Housing Instability

The notion that housing is healthcare stems from a growing body of research that links housing instability with higher rates of morbidity and mortality. There is a moral and humanitarian case for healthcare organizations to engage on the housing issue, but there also is a business case. But precisely how healthcare organizations should go about this work is not yet well established. Thus, IHI has partnered with Community Solutions, a nonprofit organization that is working to end homelessness, to examine how healthcare can play an effective role in addressing the problem.

Clinicians Are Ethically Obligated to Consider Financial Side of Care

Clinicians should include the cost of care in discussions, help patients access charity care or financial counseling, and screen patients for social determinants of health.