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Elderly heart failure patients who are at risk for rehospitalization are getting help following their treatment plan after discharge through a collaborative effort of The Methodist Hospital in Houston and Care for Elders, a community coalition of 80 private and public agencies that develops and tests pilot projects serving older adults.
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A new rule from the Centers for Medicare & Medicaid Services (CMS) makes it imperative that case managers and/or discharge planners be familiar with new coverage requirements for inpatient rehabilitation facilities and that they begin discharge planning earlier with inpatient stay, says Jackie Birmingham, RN, MSN, MS, vice president of regulatory monitoring and clinical leadership at Curaspan Health Group.
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Case managers are a hospital's first line of defense when it comes to smoothing transitions of care and preventing readmissions.
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Case managers typically have concentrated on what has to happen before the patient can be discharged from the hospital, but now, to reduce readmissions, hospitals also have to take into consideration what happens to patients after they leave the acute care setting, says Beverly Cunningham, RN, MS, vice president, clinical performance improvement, Medical City Dallas Hospital, and health care consultant and partner in Case Management Concepts LLC.
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As part of the ongoing education to prepare for Medicare's Recovery Audit Contractors (RAC) program, Cynthia Lawson, RN-BC, MBA, CPHQ, director of case management at North Hills (TX) Hospital is teaching her case management staff to think innovatively when reviewing charts.
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If you haven't started analyzing your hospital's readmission rates and the role case managers can play in reducing readmissions, it's time to start so your hospital can avoid penalties from the Centers for Medicare & Medicaid Services (CMS).
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In an effort to ensure that the patients most vulnerable for readmission stay safe at home after discharge, Lutheran Medical Center is developing a pilot program with a local home care agency to provide at least one home care visit for the majority of congestive heart failure patients going home with no services.
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By redesigning its case management program and beefing up technology, Saint Thomas Health Services reduced the average length of stay systemwide by 0.20 days and saved more than $6 million in just two years.
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In preparation for the Recovery Audit Contractors (RACs) and to improve patient flow, Durham Regional Hospital redesigned its case management department and moved to a triad model of patient care.
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