Plenary Regional Case Manager s Response to Heathcare Reform by fL3DlI


Sally Finley RN CCM
Deaconess Hospital
Challenges with Transition
from Paper to
Electronic Transfer Hand-offs
 Scanned paper H&P’s did not appear on electronic
 Discharge Med Reconciliation
 Orders to be carried out at facility
 Schedule II narcotic scripts
 Overwhelmed the recipient
    ◦ Flowsheets don’t print pretty
    ◦ Wasted paper
   Codes for responses were not provided
    ◦ Ex. Fall risk score showed as a number but did not
      include what our definition was
Feedback in Development of
Transition Report/Packet
Gerontology Network
Safety Coalition – Hand-off Sub Committee
 ◦ Standardized Referral Report
 ◦ Standardized Transition Packet
    Referral Liaison
    Caregiver accepting patient upon transfer
 ◦ Electronic Referrals – Internal & External
Council on Aging
LTAC, Rehab, SNF’s have access to EMR
 from their facility
 ◦ Upon electronic referral they can access entire
 ◦ Regional Network Services trains the staff at
   the facility
 ◦ Home Health – near future

Access to EMR
                            Patient Discharge Process Map

                                                                   Co.                          Family
                 room                                             Home            Case
              assignment                                          Srvcs           Mgmt
 admitted                                                             PT,OT ,
to hospital                                                                                Social
                                Patient in                                                 Work          Receiving
                                  ICU                                                                    facility(s)

                Patient                                             Patient                 Patient
               admitted                       Patient              receives               discharged
              to hospital                      care               discharge                  from
              ED or Reg                      delivered               order                  hospital

                                                         Teaching             Physician
                                Patient on
                                   unit                  Therapies                                       Home
Patient at                                               Facility placement
 home                                                    Home services
                                                         Insurance authorization
                                                         Home medications
                                                         Follow-up appointments
On the Road to Change

 Centralized commercial Utilization Review
 Plan to centralize Medical Necessity
 RN Caregiver to assume discharge
  planning for pattern able and predictable
 RN CM and SW focus on complex, high
  risk patients
 Redesign Case Management Model to
  address care needs and decrease
  fragmentation in care
 Redefine role of RN Case Manager, Social
  Worker and RN caregiver
 Optimize EMR utilization to facilitate care

Case Management to Care
Chief Nursing Officer
Six Sigma Black Belt RN
Unit Nurse Manager & Team Leader
Manager of Case Management
RN Case Managers
Social Worker
Bedside RN’s

Care Coordination Pilot
Previously screened 100% of patients in
 beds & intervened on different levels
 based on
 ◦   Payor
 ◦   Anticipated discharge needs
 ◦   Medical Necessity determination
 ◦   LOS & Observation time limits
 ◦   Facilitation of timely care, tests & treatment

Change in Focus of
RN Case Manager
 Developed Trigger tool for RN to consult
  Case Management for Discharge Planning
 Preliminary Indicators
    ◦   Age > 75
    ◦   LOS > 5 days
    ◦   Readmit within 30 days
    ◦   Dependent Care
    ◦   Frequent Falls
    ◦   Uninsured

Change in Focus of
RN Case Manager
Spearheaded by Case Managers
 ◦ Diagnosis of ongoing disease -High Readmit
 ◦ No PCP
 ◦ Living alone or unable to care for self
 ◦ Inadequate social support
 ◦ Homeless
 ◦ Low health literacy
 ◦ Readmit within 30 days or 3rd admit within 6
 ◦ Palliative Care Screen

Screening for Readmissions
   Patients discharged home and considered
    High Risk are called by a Case Manager post
   Non-High Risk patients are called by a nurse
    post discharge
   Electronic work lists generated off of CM
    ◦ Caller able to access chart and assess prior to call
    ◦ Caller documents in telephone encounter and ties
      call to that visit

High Risk Call Backs
   Medication changes
   Follow-up appointments
   Disease/procedure specific signs &
   Redirect back to instructions given at
   Direct patient to call PCP if appropriate

Call Back Focus
   Patient Centered Care
   Physicians – PCP & Hospitalists
   Chronic Disease Management
   Palliative Care
   Relationships with Community
    ◦ Nursing Homes
    ◦ Home Care Agencies
    ◦ Council on Aging
   Medical Home
   Payer Liaisons
Collaboration and
Relationships have never been
more important…
Angela M Beck, RN, BSN, MSHSA, CPHQ
Value Based Purchasing
       Health Care Reform
     and Case Management

Health care reform – a historic change!

Its future uncertain – but it is not going away

The effect on case management practice yet to be determined
     Health Care Reform
   and Case Management

Goals of health care reform:
• Better care (and better access)
• Affordable care and containment of costs
• Healthier lifestyles
     Health Care Reform
   and Case Management

These goals are at the heart of case management.

We know that case management brings many benefits to those
we serve!
       Health Care Reform
     and Case Management

Many provisions with some already in effect, some beginning this
year and some in upcoming years.

One provision: Value Based Purchasing
       Health Care Reform
     and Case Management

VBP – rewards quality through payment incentives and
transparency with goal to improve quality, safety and
affordability of health care services

Goal – high quality care at the lowest cost with an exceptional
patient experience.
    Health Care Reform
  and Case Management

         70% core measures
         30% patient satisfaction
      Health Care Reform
    and Case Management


Must be open to new ways of thinking and doing!

More researching of regulations, directives, transmittals from
CMS, Joint Commission standards, state variations, affecting day
to day practice
      Health Care Reform
    and Case Management

Integrated Unit Based model

Concurrent review for core measures

Communication of data to all stakeholders

A very engaged Board with monthly reporting to the Board QI
     Health Care Reform
   and Case Management

Discharge phone calls

Standardized work processes with discharge and medication

Collaboration with community partners – CPSC and Green River
Partnership for Care Coordination
     Health Care Reform
   and Case Management

Quality Caring Model (emphasizes relationships)

Spirit of Excellence Champions
Health Care Reform and
 Patient Empowerment

      Sherry Aliotta, RN, BC, BSN, CCM
              St. Mary’s Health System
 The patient is non-adherent and is
  repeatedly readmitted.
 The patient is “drug seeking” and rates
  you poorly on the HCAHP’s
 The patient legitimately decides not to
  have a treatment, but it results in poor
  outcomes or repeat admissions

What are the Implications,
A Quote from a Bedside RN
 “Why is it that the hospital gets penalized
     for all of this, and the patient has
       absolutely no consequences?”
 ◦ What’s wrong with this statement?
   Some studies suggest that in selected situations,
    using a model that emphases patient decision
    making, patients would choose a less aggressive
    use of invasive procedures and expensive
    treatments with marginal benefit. (Lenert, 2009)
   Several studies illustrate the links between
    patient empowerment, autonomy, and improved
    outcomes. In dialysis patients, Patient
    empowerment led to a statistically significant
    decrease in mortality of 39%. This contrasted
    with 24% decrease in the provider and patient

Some Empowerment Facts
   No consistent definition in the literature.
   Patient empowerment embraces the concept
    that patients have the right to make their
    own choices regarding their treatment and
    care. (Barrie, 2011)
   Empowerment is centered on the belief that
    patients should be in control of their own care
   The creation of an environment where the
    patient can behave as responsible adults, and
    that the decision is made at the point where
    the knowledge is the highest

Definition of Empowerment
   This has been represented as the minimal
    expectation of the patient continues in
    treatment all the way to active participation
    in treatment decision making. This model
    would classify engaged as:
    ◦   Active participation in care
    ◦   Attending and Preparing for Appointments
    ◦   Seeking appropriate care
    ◦   Using additional resources to maintain engagement
Factors Necessary for
   The patient understands their illness or
    conditions, the treatment options and
    risks, and has a good understanding of
    the health care system-including
    insurance benefits and other available

   Recognize the varying levels of preference
    regarding collaboration. Studies show
    that the elderly and patients with more
    advanced or serious illness may have a
    decreased preference for collaboration.
    Studies showed there was more conflict
    and distress when the patient preferences
    are not met by their provider. This lack of
    alignment with decision making results in
    poor adherence.

 It is possible to be engaged, but not
 Lack of commitment may result in unfilled
  prescriptions and disregard for other
  treatment recommendations.
 On the other hand, high levels of
  commitment may help the patient through
  those times when they are experiencing
  unpleasant side effects or not responding
  as anticipated.

   The patient needs to be able to
    understand and cope with the uncertainty
    of outcomes. They must be able to
    tolerate this to proceed with treatments in
    the face of the unknown.

Tolerance of Uncertainty
   This model requires the case manager to
    continue to acknowledge and foster the
    patient’s autonomy.
   The patient has to have trust in their case
    manager and providers of care so they know
    when to proceed and when to challenge.
   Patients provided with this environment and
    opportunities do perceive their level of
    competence and their ability to handle their

Underlying Assumptions
   Case managers often deal with patients who suffer repeated
    and debilitating exacerbations, live on the streets, without
    proper food and clothing, and with isolation and a lack of social
    It is hard for us to imagine that these circumstances would be
   Our ability to focus on empowerment is further complicated
    when their choices don’t make sense and seem irrational,
    irresponsible, or unsafe.
   We each have our own level of tolerance for accepting their
    choices. (Purkis, 2009).
   Our decisions are not really about whether we can support
    these patients in their choices, but whether we can continue to
    support patients who chose to live at risk.
    In other words, the patient is only free to exercise those
    forms of freedom that keep them within the bandwidth of
    acceptable behavior

The Reality
Type 1: Divergent Nurses                                           Type 2: Convergent Nurses
Their response were always holistic                                Responses more reflective of the bio-medical model

Analyze the interactions of the relationships between health,      Emphasis on individual behavior change by patients controlled by
illness, social structure, and culture                             nurses.

Consider the patients total environment and how these could        Seek to empower patients by moving them from unhealthy
impact the patient’s health                                        lifestyles to healthy lifestyles.

Respects the patient’s views and tries to understand them in the   Impose behavioral control by using fear and blame
context of their social lives

Refuses to make a quick decision based on the medical criteria     Power over approach

Considers a range of solutions to what may appear as a single      Patients are recipients of their professional knowledge

Power with approach
Attempts to find common ground between them and their

Nursing Characteristics
 “Pay to Play” increased stake in the
 Paradigm Shift to Recognize the Patient
  Has the Power, and We Need to Provide
  the Facts and Options
 Health Care Provider Response

How will HCR Impact

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