Hospital Case Management : the Monthly Update on Hospital-based Care Planning and Critical Paths

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It’s been nearly four years since the Centers for Medicare & Medicaid Services announced its Two-Midnight Rule, but hospital staff still are grappling with the gray areas in the rule. Some hospitals classify patients as receiving observation services if their status isn't clear-cut, potentially increasing patients' out-of-pocket expenses and making them ineligible for a skilled nursing stay. Hospitals should have case managers at all entry points to ensure that patient status is correct up front. Case managers should conduct self-audits of short-stay patients before the bill drops, make corrections, track the self-denials, and educate physicians on where the mistakes are...

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To accommodate its Native American patients, who make up about 40% of the patient population, Flagstaff Medical Center offers traditional food and has a traditional healer on staff. The hospital has full-time Navajo interpreters as well as 39 staff members who are back-up interpreters. Instead of giving Native American patients a large packet of information they may not understand or trust, care managers work with the primary care providers on the reservation and ensure they are aware of the hospitalization at the discharge plan...

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As the population becomes more divers, it's important for case managers to be aware of their patients' cultural beliefs and practices, and respect them in order to build trust and ensure that patients and family members will follow the care plan. Hospitals should provide comprehensive education on the culture of the patients they serve, hire staff that are from the ethnic groups they serve, and revamp their educational materials so that they are in all the languages their patients speak. Case managers should have general information on patients' cultures but also should conduct a detailed assessment to find out the beliefs and practices of each individual patient, rather than making assumptions...

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Thanks to a series of initiatives to focus on at-risk patients after discharge, Flagstaff Medical Center has avoided readmission penalties for four years and consistently has a 12% all-cause Medicare readmission rate. Inpatient care coordinators assess patients in the hospital and refer those who are at risk to the outpatient care management team, which visits the patients in the hospital and determines the appropriate post-discharge interventions. Depending on their risk scores, patients may receive home visits from coaches, telephone calls from care managers, telemedicine monitoring, or a combination of interventions after discharge...

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Length of stay dropped and patient satisfaction rose when Emory Saint Joseph’s Hospital in Atlanta began holding Structured Interdisciplinary Bedside Rounds (SIBR). The rounds are held daily, last about an hour, and are attended by physicians, nurses, case managers, pharmacists, and other disciplines providing care for the patients. As team members discuss the patient's condition, the care plan, and discharge needs, they encourage the patient and family to give their input. Initially, the team members were concerned about finding the time for the rounds, but they report the rounds save time by bringing the team together and eliminating phone calls and trying to track other clinicians down...

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Multidisciplinary rounds that bring together the entire treatment team and, often, patients and family members, are a key in relieving the chaos that often occurs on the day of discharge. The rounds increase communication and promote collaboration around the discipline by keeping everyone on the treatment team on the same page. Rounds save time for case managers because they hear every discipline's plans for their patients at the same time and everyone on the team avoids fielding multiple phone calls during the day...

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