Written by: Joanne Wetch, Director of SCP Consulting Services

With the expansion of alternative/bundled payment models, a focus on value-based care delivery, and the inclusion of care coordination in the National Quality Strategy, the role of Case Management is becoming increasingly important. In fact, Case Management should be the linchpin in an effective value-delivery strategy.

Managing the financial risk in value-based reimbursement models requires optimization of care settings, avoidance of duplicate services, polypharmacy management, early detection and intervention to avoid ED visits and readmissions, and re-assessment of the care plan as the patient’s condition changes. Doing these things within the inpatient setting is one thing; doing them—and doing them well—across the full continuum of the patient’s episode of care is quite another.

Historically, hospitals have focused on what the Centers for Medicare and Medicaid Services (CMS) still refer to as "discharge planning." However, Case Management is so far beyond just discharge planning. Case Management is the center of care coordination and transition management across the continuum.

As hospitals redesign care in response to value-based care, it becomes necessary to evaluate critical aspects of the Case Management function:

  • The breadth of the Case Management team: Where and how are they coordinating care beyond the ED and nursing station? Are they adept at assessing each site of service within the context of value-based reimbursement? Should our inpatient Case Managers extend their reach across the continuum or should we have a specialized post-acute Case Management team?
  • Approach to high-risk patient populations: How do we identify and stratify our populations in need of a specialized approach? 
  • Patient and family as part of the care team: How do we effectively coordinate with this critical component? How do we rate our ability to teach, motivate, and engage? Have we looked at alternatives to traditional paper discharge instructions? Do we have a telehealth strategy?
  • The Case Management platform: How do we share clinical information as our patients’ transition? Have we made it easy for our Case Managers to communicate with providers outside the hospital? Are we utilizing technology to its full extent? 
  • Provider engagement across the post-acute network: Have we established expectations across the continuum or are we focused only on hospital outcomes? How can we collaborate with our physicians for clinical practice improvement activities as part of the merit-based incentive programs (MIPS)?
  • Readmission strategy: What gaps have we uncovered that lead to ED returns, medication mismanagement, less than optimal outcomes, noncompliance, and customer dissatisfaction? What are we doing to eliminate these gaps? 
  • Transition from the hospital: What can we learn or incorporate from transitional care models that exist in the market (e.g., Project BOOST – Better Outcomes by Optimizing Safe Transitions, Project RED – Re-engineered Discharge, Care Transitions Intervention®—CTI, Transitional Care Model—TCM, Guided Care® Comprehensive Primary Care of Complex Patients, others)?

As hospitals and health systems look beyond their walls at patient care coordination and transition management, we have seen new roles and transitional care models emerge.

I propose that it does not matter if you adopt an existing model, build your own, or use an Outpatient/Ambulatory Case Manager, Nurse Navigator, Transitional Care Manager, Guided Care Nurse, or Transitions Coach.

What matters is that you have in place a clearly-identified practitioner with the requisite knowledge, skills, abilities, and defined processes to manage the goals of care that they all have in common.

As we honor National Case Management Week (NCMW), we recognize that Case Management doesn’t just happen—and without it, patient care suffers. It takes an effective leader, and a strong team, that is adequately trained and supported on a daily basis to successfully coordinate the work of the healthcare team and manage transitions across the episode of care.

It has been an honor to work in and with hospital and health system Case Managers for over twenty-five years. I look forward to the excitement that our next generation models bring. And I look forward to your comments in regards to how you see the role of the inpatient Case Manager changing to meet the needs of a value-based delivery system.