Hospital Case Management – March 1, 2023

Indiana Medicaid Officials Embrace Care Coordination Project

A project to improve care coordination for children with complex medical needs revealed well-trained nurse care coordinators could manage a 100-patient caseload and improve outcomes. Nurse care coordinators were embedded in primary care provider offices and were trained to provide care coordination, including helping patients with medical and social needs.

Inside the Indiana Complex Care Coordination Collaborative

Indiana’s Medicaid program administrators found value in embedding nurse care coordinators in primary care practices to address social determinants of health and transitional care issues in a population of children with complex medical issues.

Detailed Resource Tools for Care Coordinators and Case Managers

Case managers and care coordinators need such a wide range of knowledge about community resources to address their patients’ social determinants of health that resource tools can be a huge time-saver. For a care coordination program involving complex pediatric patients, leaders developed a series of nearly two dozen resource guides they call playbooks.

Patients with Parkinson’s Disease Often Lost to Follow-Up Care

Telehealth visits can improve continuity of care, quality of life, and overall health for patients with Parkinson’s disease, recent research shows. Although Parkinson’s affects 1.2 million people in the United States, there is little research on people in later stages of the disease.

Care Transitions Through ACHIEVE Study Score Points with Patients

Care transitions across organizations and the community require better collaboration and communication among providers and social service organizations, according to recent research. Patients benefited from improved collaboration. They reported feeling better supported and cared for by providers involved in a care transition project.

Hispanic Patients with Diabetes Need Better Care Transition Models

About one in 10 Americans are diagnosed with diabetes, and the Hispanic/Latino population is disproportionately affected. Their risk is higher — and their outcomes are worse — than the white, non-Hispanic population. Researchers designed a transition of care model and pilot to see if they could improve outcomes.

Case Managers Can Prepare Families for Memory Care Placement

When patients with memory care needs are hospitalized, case managers often are the first — and sometimes only — point of contact to discuss transition options. When the transition includes moving into a memory care community, it is important for patients and their families to know what to expect.

How Case Managers Can Prepare for Public Health Emergencies

Public health emergencies (PHEs) can happen at any time. If not handled correctly, PHEs can quickly throw a hospital and its staff into a tailspin. But if a hospital is adequately prepared for a PHE, it can benefit other healthcare partners and the community.