Perspectives from a Hospital Case Manager
In the evolving healthcare landscape, hospital case managers play an integral role in care coordination and seamless transition planning. Their days are spent ensuring patients are in the right status (e.g., inpatient vs. observation), helping the inpatient care team provide efficient care in the right setting, managing patients at high risk for readmission, and identifying patients with discharge needs and developing a transition plan.
“One of the most important responsibilities of case managers is helping patients find the right post-acute provider,” says Linda Sallee, former vice president of case management at Inova Health System and now a consultant at Huron.
Needs-Based Transition Planning
The transition planning process is initiated with a discharge assessment to determine if a patient needs post-acute support.
“It can take a long time to find the right post-acute provider and obtain the authorization from the payer. Therefore it is important to start transition planning as soon as possible. We encourage case managers to assess a patient’s needs for post-acute care on the first day of their hospital stay,” says Teresa McNulty, a consultant with Huron who has worked in case management for 20 years.
If the need for post-acute care exists, the case manager should begin the transition planning process, starting with a determination of the appropriate post-acute level of care, such as an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), home health, long-term acute care hospital or hospice. This determination is based on objective criteria (e.g. the capacity to make measurable improvement in an IRF setting), medical necessity criteria (e.g. the need for skilled nursing services around the clock) and payer requirements (e.g. a three-day inpatient hospital stay within the last 30 days required for Medicare reimbursement).
Providing Information on Post-Acute Providers to Patients and Families
In discussing post-acute care options, case managers should make a conscious effort to preserve patient choice. However, it is appropriate to provide information to patients and their families to assist in their decision-making. Leading practice is for the case manager to send a referral to facilities that can meet the patient’s post-acute needs and are in-network for their plan. The case manager then provides the list of “accepting” providers to the patient. It is appropriate to share quality information such as the Star Rating from the Centers for Medicare and Medicaid Services Nursing Home Compare website or the U.S. News & World Report Best Nursing Homes ranking. In addition, case managers should provide information on payer coverage for different post-acute care options.
Leading Practices of Preferred Post-Acute Providers
Hospital leaders are focused on decreasing length-of-stay (LOS) and reducing costs while expanding their virtual capacity to serve more patients. For most hospitals, discharges to post-acute facilities such as skilled nursing facilities offer the opportunity to do just that. Post-acute providers who have a timely and efficient intake process help hospitals manage LOS by avoiding delays in the discharge process.
Leading practices of post-acute providers who are good partners to hospitals include:
- Automated referrals: The ability to accept automated referrals and respond in a timely fashion with an accurate response. If a post-acute facility indicates they will accept a patient, then later reverse that decision, it is detrimental to a positive working relationship.
- Easy intake process: The best post-acute provider partners have clear and efficient processes for communicating the discharge plan and clinical information needed to transition the patient safely to the post-acute care team.
“In addition, being open to transfers at least 12 hours per day is helpful. There are still many providers that do not accept patients after a certain time, such as after 2 p.m., or do not have admissions staff after 4 p.m.,” Sallee says.
- Willingness to partner on clinical initiatives: Strong post-acute partners are willing to collaborate with hospitals on improvement initiatives such as understanding and addressing root causes for readmissions and training to improve their ability to accept patients with clinical needs they may be unfamiliar with, such as special wound care.
“Strong partnerships between hospitals and post-acute providers that address barriers and challenges lead to a better transition process and benefit all parties, especially the patient,” says Sallee.