Hospital Case Management – June 1, 2023

Health Systems Improve Post-Acute Transitions

Transitioning patients from the hospital to skilled nursing facilities has become more difficult for case managers since the COVID-19 pandemic began. Case management leaders from several different hospitals have developed solutions.

Hospital Cuts Readmissions in Half with Process Improvement Strategy

Employees at HonorHealth Network in Phoenix work toward reducing readmissions. This is why the health system created a process improvement program that addresses the challenges of frequent users. In 2022, the program reduced readmissions among patients with complex care plans by 51%.

Standardized Process for SNF Transitions Helps Prevent Readmissions

Using Lean methodology, Monument Health in Rapid City, SD, created a care transition process that reduces excess hospital days, prevents readmissions, and shortens the time it takes from discharge order to the patient leaving the hospital.

Discharge Navigators Facilitate More Efficient Transitions

SNF beds were limited in one hospital’s region, even before the COVID-19 pandemic decimated nursing home staffing across the United States. ECU Health’s solution has been to assign a discharge navigator to work on obtaining authorizations for transferring patients to SNFs. Instead of waiting for the SNF to obtain authorization for a particular patient, the discharge navigator handles this task.

Reservation Program Saves Beds, Prevents Readmissions

A health system tackled the challenges of transitioning patients to SNFs through a relationship with a multisite SNF. Together, the organizations created a bed reservation program, which results in a smoother and more effective transition process.

Embarking on Case Management Research

As case managers go about their days, they are constantly discovering and solving problems, often without even realizing it. Part of the role is to troubleshoot issues with discharge, utilization management, and more — but once the issue is resolved, that often is the end of it. However, when case managers seek solutions for their problems, they are engaging in research.

The Importance of the Physician Advisor

The physician advisor role has been evolving over the last couple of decades. Case managers are discovering their relationships with these clinicians can be incredibly valuable when made a priority.