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Seniors who are at risk for readmission to the hospital are getting support that helps them stay healthy at home by Care Transitions coaches at SCAN Health Plan, a Long Beach, CA based health plan that provides coverage for Medicare and Medicaid beneficiaries.
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Declining rates of hospitalization have discouraged primary care doctors from seeing their patients in the hospital and encouraged the growing use of hospitalists.
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A year after Saint Joseph-London Hospital in London, KY, began a heart failure readmissions program, 30-day readmissions dropped from 27.7% to 15.9%. A similar program for patients admitted for acute myocardial infarctions (AMI) reduced the readmissions rate from 23% to 10% in a short time.
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When the Inpatient Prospective Payment System (IPPS) final rule for 2012 was issued, the Centers for Medicare and Medicaid Services (CMS) stated that its goal is to encourage hospitals to provide higher quality of care at a lower cost and to promote greater efficiencies across all care settings and throughout the entire health system.
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Most of the items in in the box "Characteristics and Core Competencies of Potential Candidates" (below) are inherent and/or learned over time.
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Your job descriptions should clearly define the minimum amount of education that you require for the role of case manager or social worker.
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Orientation should be geared to the experiential level of the new staff. The novice case manager will require a different orientation than the experienced case manager. You will need to determine this based on an assessment of the new staff member.
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Healthcare reform mandates, new reimbursement requirements from the Centers for Medicare and Medicaid Services (CMS), and pressure from payers to keep patients out of the hospital and emergency department all mean that hospitals need to do a better job of transitioning patients to another level of care.
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After Summa Health System and Akron, OH, area nursing facilities formed the Care Coordination Network to improve communication throughout the continuum of care, lengths of stay and readmissions for patients transferred to facilities in the network dropped.
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A pilot project providing coaching and follow up for heart failure (HF) patients who are readmitted frequently resulted in a 50% drop in the readmission rate at Indiana University (IU) Health Ball Memorial Hospital in Muncie, IN.
