Hospital Case Management Advisor

Most Recent Updates
by Phoenix Medical Management, Inc.


Hospital Case Management is a compilation of several services often aligned under the hospital case management program umbrella. Here is our collection of Hospital Case Management Advisories related to those servicesAs always, we welcome your thoughts or your critique. Feel free to send an email to editor@phoenixmed.net.

HIPAA Compliant SmartPhone

Mobile devices, including cell phones, tablets, and laptops, are increasingly ubiquitous in many hospitals. They are generally convenient and productive. But with the increased usage of SmartPhones to communicate between case managers and physicians, hospital execs should address the potential risk regarding electronic PHI. [...]

Senior Medicine: When More Isn't Better

A movement to slow down excessive care runs into the culture (and business) of the healthcare industry. This article was written with the support of a journalism fellowship from New America Media, the Gerontological Society of America and the Silver Century Foundation. [...]

Preparing for Care Coordination

In a departure from most graphics depicting a care coordination model, our understanding of a patient-centric approach works best when the patient has a partner to help navigate through the complexity of the health care system. The goal is to engage, educate and empower through [...]

Initial Patient Assessment and LACE

The LACE is a validated risk assessment tool to identify patients who may be at risk for readmission. With staffing shortages that limit the volume of patients who can be managed by a case manager, many hospital case management leaders are relying on the LACE to target patients who would benefit most from focused care coordination. [...]

Care Coordination and Resilience

To be successful in a risk-based population health environment and to fully serve the people who comprise those populations, we need different approaches to delivering health care. CareOregon embeds Master’s prepared Psychology Counselors, Social Workers, and Family Counselors known as "health resilience specialists" into Patient Centered Primary Care Home teams. [...]

Emerging Fourth Generation Hospital Care Management

Fourth generation, patient-centered care management is a value-based model of care that puts patients at the center of clinical decision-making, and respects the patient’s experience, values, needs and preferences in the planning, co-ordination and delivery of care. Central to this model is the relationship between the patient and the care manager who serves as the patient's proactive advocate. [...]

Care Coordination PROMs

"PROMs are precisely the missing link in defining a good outcome. They capture quality-of-life issues that are the very reasons that most patients seek care.” Neil Wagle, MD, MBA, Partners HealthCare, Brigham and Women's Hospital, Boston. [...]

Medics as Transition Coaches

There are hundreds of military combat medics and corpsmen returning from Iraq and Afghanistan who need jobs and who could help preserve the health of patients released from hospitals across America. Wouldn’t it be ideal if they could do what HonorHealth's transition coaches are doing? Originally posted July 1, 2014 but worthy of your attention today. [...]

Hierarchical Condition Categories: What's All The Buzz About?

There is quite a bit of discussion around Hierarchical Condition Categories (HCCs) these days. And for good reason: It is the risk adjustment model used since 2004 to determine reimbursement for commercial Medicare Advantage plans. And now the HCC framework is progressively being applied to numerous healthcare reform initiatives. [...]

Can States Survive The Per Capita Medicaid Caps in the AHCA?

Rationing care to fund high-income tax cuts is not just the byproduct of the Republican Medicaid plan, but rather at the heart of it. The motivation of recently passed bill - to end the guarantee of coverage for those eligible for Medicaid, and replace it with spending caps — seems to be more to do with supply-side fiscal policy than health-care reform. [...]

We Need a Standardized Vocabulary

The traditional "task-oriented" case management program is outdated as the team members have become essential progression of care consultants to the medical staff and leadership. Might be time to standardize terminology to avoid confusing our clients and customers. [...]

Management experience is more important than a nursing license.

While patient care and clinical experience are important skills to advance to a nurse manager, case management director candidates should be able to demonstrate experience in areas such as finance, informatics, and marketing in order to innovate and lead in a time of change and shrinking budgets [...]

Are We Killing Our Young?

The Blind Men and the Elephant is an ancient parable often cited as a warning for people who promote absolute truth. Because our perceptions and life experiences often lead to overreaching misinterpretations, absolute truth is illusive. How can a person with limited knowledge turn that into the one and only version of all reality? [...]

Healthcare's dirty 'little secret': No one is officially coordinating care in the hospital

Poor care coordination creates negative consequences for both patients and healthcare providers but it remains an illusive goal in many hospitals.Perhaps because it is often confused with transitions of care.To optimize care coordination,it's vital that execs look at it as a longitudinal process of advocating,influencing,facilitating,and promoting safe,efficient,effective,and timely care throughou [...]

Preferred Post Acute Providers

Hospitals are picking their preferred post-acute care providers which play such an essential role in ensuring that patients receive the care they need to heal and have a smooth transition back to a community-based setting, typically after a discharge from a hospital. [...]

Where is Hospital Case Management

Hospital case manager failure in one hospital affects us all. With the shift to value based care management, its time to examine your hospital program and objectively see if it reflects professional standards of practice and meets new marketplace expectations. [...]

Advocacy and Excessive Blood Draws

Excessive phlebotomy has consistently been implicated as one of the major causative factors in developing hospital acquired anemia and increased risk of morbidity and mortality. If nurses and care managers are aware of this evidence, should their shared advocacy obligation be exercised on behalf of their patient? [...]

Emphasis back on Volume

Last year, U.S. News & World Report expanded it's Best Hospitals for Common Care report and found that patients who receive 5 common surgical procedures and medical conditions at low-volume hospitals have a much higher risk of death or complications, while patients at higher-volume facilities have a reduced risk. [...]

Transitional Care

Transitional care is a range of time limited services that complement primary care and are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and across settings [...]

After You Say Hello

When it comes to helping patients understand the concept of care management, a couple of good words at the first visit may go a long way to reduce patients concerns and confusion. [...]

The Discipline of Value Based Case Management

Case management directors and their executive sponsors have the opportunity to rethink and challenge their own assumptions and the practical implications of a new way of thinking about hospital case management programs. That means they must both bring a different set of "what-ifs" to the table and a multidimensional view of the current marketplace, new performance expectations, & desired outcomes. [...]

The enemy is not death. The enemy is needless suffering.

Among hospice staff, it is called “getting it.” One says, “He doesn’t get it,” “I think she gets it,” or, “They definitely get it.” It is a little hard to define, but as with pornography, you know it when you see it. [...]

Don't 'manage' denials - Prevent them.

The only way to prevent denials is knowing what actions are causing them. A root cause analysis begins with 'first pass' denial information transmitted by the payer to the hospital via the 835 report. [...]

A New MOON Rises

CMS introduced a free text field in the written MOON form requiring that someone specify the reason(s) a patient is being placed in observation. The chief compliance officer should consult with leadership to decide which staff members are appropriate to complete that section. But you can make it easier by using check-boxes. [...]

Determining need for inpatient care

Patients may be placed in observation when the patient’s condition is rapidly changing, further diagnostic testing is required and it is not clear if inpatient care is needed. After several hours, but no more than 1 midnight, a reassessment is made to determine if the patient requires inpatient admission, or may be discharged and receive followup in the outpatient setting. [...]

Physician-Level Practice Variation

That physician factors can explain both the overuse of unnecessary services and the under-use of clinically indicated services across clinical entities suggests physician-level variation is not only pervasive, but substantially impacts the cost, quality, and value of care delivered across a wide spectrum of clinical services. [...]

5 Easy Pieces

The goal of care coordination is shown in the middle of the diagram.The colored circles represent some possible participants,settings,& information needed for effective CC. The blue ring connecting the colored circles is CC—namely, anything that bridges gaps & improve coordination. [...]

What Can the Dallas Cowboys Teach Us?

Huddle time must become a part of everyone's daily routine. And that will happen if participants perceive it to be of value. So, each member must come with knowledge about their patient and progression-of-care recommendations. Experiment with different participants and how information can be shared with non-participants. Establish a time-limit and stick to it. [...]

Care Management in a Value Based Marketplace - Part 2

Researchers have long argued that the survival of an organiation is dependent on its continuous interaction with its environment. The hospital environment includes the current and changing marketplace, governing regulations, and the available resources. This same thinking applies to care management which must innovate to stay current. [...]

Care Management in a Value Based Marketplace

The transformation to value-based health care is well under way. Some organizations are still at the stage of pilots and initiatives in individual practice areas. Other organizations, such as the Cleveland Clinic have undertaken large-scale changes involving multiple components of the value agenda. Making this transformation is not a single step but an overarching strategy. [...]

Medicare's Nursing Home Compare

New quality measures for skilled nursing facilities will be added to Nursing Home Compare beginning in April. Data for six new quality measures — some based on Medicare claims, others on MDS data will be useful to consumers and to care managers as they provide important information about quality of care outcomes that wasn't covered previously on Nursing Home Compare. [...]

Transition Clinics

A Transitional Clinic is one of the innovative approaches to value based care and a way of keeping patients connected to the highest quality care as they make the transition from the hospital to home or a post-acute care facility. [...]

Football Team at the Obamacare Buffet

How an all-you-can-eat menu is making health insurance plans more costly and stingy. Insurers re switching out the lobster for fried chicken, and charging more for it. This article appeared in the NY Times, Sunday, Sept 25, 2016 [...]

Predictive Analytics is transforming health care

Hospitals have a powerful new tool — predictive analytics — that can help them use their untapped troves of data to improve patient care, become more efficient and lower costs. The shift from FFS to value-based reimbursement is driving the need for sophisticated analytics systems that can quantitate and track quality measures. [...]

Transmittal 541 Comes Alive

If admitting physician's documentation, including history and physical and progress notes, doesn’t support medical necessity of an inpatient surgical procedure, the surgeon’s Part B claim for performing the procedure can be denied. Transmittal 541 continues to allow the denial of the physician’s claim without requesting records from the physician, meaning the physician’s claim may be denied based [...]

Advocacy and the Care Manager

Patient advocacy is not new for case managers. It is a moral obligation traced back to NYC social workers helping newly arriving immigrants. But hospital case managers do not always act at an optimal level of advocacy and often accept only what they can do. Many consider advocacy contextually complex, and in some facilities, a controversial and risky component of case management practice. [...]

The Future and the Case Management Program

The threat to American hospitals began with the introduction of the prospective payment system, continued through the 1999 publication of the IOM report, To Err is Human and continues as execs struggle to prepare for the future. In response to these challenges and the additional pressures of increasing costs and new payment models,a progressive model of case management is essential. [...]

Bend the Cost Curve and Eliminate Waste

Excess costs across the healthcare system, combined with lower than acceptable value affects all of us. Expenditures per capita on federal, state, and local levels and as a percentage of gross domestic product are rising in spite of efforts to curtail healthcare costs. And although quality outcomes have improved, so has the cost of care. [...]

Three Easy Pieces

There are many changes that need to be made to transform a traditional, task oriented case management program into a model which more closely reflects the changes in the marketplace. These three strategies - reorientation of the care manager's role, physician education, and a PARC program will help the program Director close the gap between fee for volume and fee for service. [...]

Accountable Care Units

Accountable Care Units (ACU) generally have four key features: unit-based Hospitalist teams; structured interdisciplinary bedside rounds; unit-level performance reports and rewards for achieving pre-determined outcomes; and unit co-management by the nurse manager, the care coordinator, and medical director. [...]

Adapt and Thrive

Responsible case management adaptation encompasses the strategies, actions and partnerships through which programs adapt to marketplace impacts because it provides some improved function and creates shared benefits for the stakeholders they serve. [...]

Analytic Intelligence

Bundled payments, global payments, and shared savings plans. All new as part of healthcare's reform initiatives driven by the ACA. To stay financially viable, hospital leaders must understand their total costs in order to manage them. [...]

The Hospital Care Manager

Care coordination, the key component of a hospital's contemporary comprehensive case management program, can improve the clinical and economic outcomes for high-risk patients and positions the care manager's integration into transitional care and population health. [...]

True North

Every case management leader must discover their True North and stay on course of their beliefs and values throughout their career, so they can realize the fulfillment of leading others with a common purpose. [...]

Avoid Overtreatment

Swedish Medical Center in Colorado embraced Choosing Wisely recommendations against too-frequent ordering of lab tests. They undertook a review of ordering patterns and found five or six out of a staff of 60 physicians were responsible for 50 percent of daily labs. Hospital leaders created a simple e-mail based intervention that included data on physician ordering patterns, coupled with educationa [...]

The Feds are Watching

Halifax Hospital Medical Center and Halifax Staffing Inc. (Halifax), a hospital system based in the Daytona Beach, Fla., area, paid $85 million to resolve allegations that they violated the False Claims Act by submitting claims to the Medicare program that violated the Physician Self-Referral Law, commonly known as the Stark Law. [...]

PARC + PDC

There are pros and cons of having hospitalists briefly leave the hospital units to see patients in the post discharge clinic. On the downside, there may be a temporary gap of continuity with the patient's primary care physician. On the upside, patients benefit in terms of meeting with someone who actually knows the care they received in the hospital. [...]

Culture Eats Strategy for Breakfast

The reasons for variation among hospitals in mortality rates for patients with acute myocardial infarction are not well-understood. A 2011 qualitative study of interviews with staff of high- and low-performing hospitals found that such characteristics as organizational values of excellence, innovative approaches to problem solving, and good coordination among clinicians distinguished hospitals wit [...]

Outcomes Count for Patients and Care Managers

The changes taking place in hospital case management programs are the result of forward thinking leaders who recognize that hospital case management programs must keep pace with the changing marketplace. Progression of care must be safe and efficient and often the care manager is the only consistent resource available to the patient. [...]

The Observation Unit

The efficiency achieved by using observation for up to 24 hours rather than a typical short stay admission reduces the patient's exposure to the well documented dangers of inpatient hospitalization. [...]

Physician Advisors

A Physician Advisor(PA)brings a unique skill set to the clinical environment to help the medical staff navigate through the rules governing the business of healthcare. Whether working with the utilization review specialists, the care managers, or the clinical documentation improvement experts, the role of the PA is an essential ingredient to navigate the turbulent waters of a value based system. [...]

Group Medical Visits Are Catching On

In a typical doctor's visit, you wait around for a while, get your vitals checked, and spend a few minutes alone in a room with a physician. It's private and short. Some doctors, frustrated by a relentless schedule of 15-minute, one-on-one visits, are experimenting with appointments that are neither. [...]

PhoenixMed at ACMA 2016

Probably the most exciting part of a national conference is the opportunity to network with colleagues, friends, and clients from across the Country. The 2016 ACMA Conference held in Tampa Florida earlier this week was no exception. [...]

Hirsch's Law

There is no national observation rate benchmark. CMS does not publish such data and any organization claiming to have such a rate is just creating it from its own database, with no guarantees that they are following the rules or even calculating their observation rate the same for all facilities in the “benchmark group.” [...]

The Business Case For Hospital Case Management

Physician relationships, a growing number of hospital-based physicians, protective gatekeeping, promoting evidence based practice and overcoming delivery-of-care barriers are just some of the reasons to reinvent a hospital’s case management program, say contributors Stefani Daniels and Richard Reece, M.D. [...]

The Myth of Length of Stay

When several readers brought to our attention that this article is no longer available on HealthLeader's Media web site, we decided to post it on our blog. It's as relevant today as it was when origianlly published in 2008. [...]

Beware of HIPAA Zealots

Fear of punishment and lack of training can lead to case management professionals to misinterpret the law's requirements. [...]

Is It Time To Dump The Pagers?

The advent of cellular phones led to a rapid decline in beeper use, but they are still in widespread use. If doctors were among the first adopters of paging technology, they will almost certainly be the last to abandon it. [...]

Do You Have A PARC Ranger on Your Team?

Approximately 53% of hospital discharges are considered 'routine' and typically include disch to home, disch to home w/HH or return to an ECF or SNF. Post acute plans for these patients are generally developed by the nursing staff with the logistical assistance of a PARC. Using an HL7 interface, a web based portal to an automated post acute application can speed up the discharge process significan [...]

The Hospital UR Plan

A solid UR plan should provide clarity of purpose and application of processes as they relate to managing regular Medicare and Medicaid patients through each acute episode of care, from admission to discharge. [...]

2016 Case Management Education Programs Announced

Start the New Year off on a best practice foot and bring in the PhoenixMed experts to help case managers and UR specialists understand the new marketplace, how to engage their medical and clinical colleagues in efficiently managing progression of care, and to translate the eithical obligation of advocacy into practical, real-time resource management monitoring. [...]

The Bad Boy of Turing

Turing Pharmaceuaticals' CEO Martin Shkreli,raised the price of the life-saving drug Daraprim from $13.50 to $750 per pill. Daraprim is used to treat toxoplasmosis, a condition which can prove deadly for the unborn children of pregnant women and for immunocompromised individuals like AIDS or cancer patients. These vulnerable populations will now have to pay over 5,000% more for their treatment. [...]

Who Needs A Hospital Care Manager?

The professional practice of hospital case management is a collaborative process between the patient, the physician, and members of the clinical team to pro-actively influence and advocate for a safe, cost efficient, clinically effective progression-of-care through the acute episode of care and into the community. The question is: Which patient would benefit most from this service? [...]

Payer Contracting - Part of Revenue Cycle Integrity

Payer contracts are typically silent about UR requirements. The contract refers the provider to the manual which, in essence states that the hospital 'will cooperate' with the payer's UR processes. And that means when they ask you to jump, you will cooperate and ask 'how high.' The only way to remedy this imbalance is to negotiate utilization review language that creates a win-win situation for [...]

Persuasion is The Language of Care Manager Success

Advocacy is the hospital care manager's primary ethical obligation. As the patient moves through the episode of care, the care manager must be able to facilitate timely delivery of care, they must make sure the care is appropriate to the patients reason for admission and their personal preferences, and they must intervene when care or services may not be in the patient's best interest. [...]

A Brief History Lesson

This article is actually a letter sent to M.A. Biosiani and C.Y. Jurgens, authors of an article that appeared in Lippincott's Professional Case Management 2015 July-Aug;20(4). 188-97. [...]

Gawande's Being Mortal

Dr Gawande does a great job in speaking to our encouraged belief that medical science can cure us of almost anything as long as we try absolutely everything. This is far from the reality of the situation for medical care and our most serious human diseases. [...]

Data-Driven Case Managegment: An Important Part of Population Health

Achieving value-based care is nearly impossible without an effective case management program. As we approach the 2015 National Case Management Week, October 11-17, please take time to learn more and embrace the contribution of case management. [...]

The Case Manager and Mandatory Bundles

The Comprehensive Care for Joint Replacement (CCJR) may be the first mandatory bundle proposed by CMS, but it won't be the last in the industry's move from fee-for-service to fee-for-value. A robust care coordination program that begins in the hospital and extends through-out the continuum will quickly become a best practice. [...]

2016 OPPS Rule Moratorium Update

The RAC moratorium expires on Sept 30 and will not be extended. Rather, as part of the proposed 2016 OPPS rule, the CMS announced that the QIOs will be doing the reviews. [...]

Lessons From Near Misses

A near miss collision in aviation would have made front page news and sparked a wide investigation. Paul Levy asks why isn't the same investigation conducted when hospitalized patients experience a smiliar 'near miss.' [...]

ICD-10-CM No Turning Back

Over 25 countries already adopted ICD-10 to classify diseases and related health problems because of the many benefits it provides in the provision of patient care and collection of data. ICD-10 will also improve quality of care and its documentation. (Portions of this article appeared in Health Data Management) [...]

Medical Necessity and the Revenue Cycle

Too often, the scope of the utilization review specialist is on the application of InterQual or MCG guidelines and whether the available medical documentation reflects those guidelines. If the documentation does, the assumption is made that the patient is eligible for hospital admission. Unfortunately, that is not always the case. [...]

Does My Mother Really Need That Central Line?

Congratulations to Dr. Anton Travis Manasco, PGY2, and Dr. Judy Linden, Associate Professor of Emergency Medicine and Vice Chair for Education, for their publication in the JAMA on the role of palliative care in emergency medicine! [...]

A Skeptics Guide to Health News and Diet Fads

This has little to do with hospital case management but as we all struggle to increase healthcare literacy among non-healthcare industry patrons, this podcast and the accompanying Consuumer Handbook is a good start for the conversation. [...]

The NOTICE Act

Congress unanimously approved a bill that requires hospitals across the country to tell Medicare patients when they receive observation care but aren't actually admitted to the facility--a difference that most patients miss until they receive their medical bills. [...]

Enhance the Med-Rec Process

Create a multidisciplinary team to identify where your hospital can best improve its medication reconciliation process, including how changes to your electronic health record (EHR) and greater use of pharmacists can make reconciliation a simpler and more effective task. [...]

When Life Changes on a Dime

We have all been there--one minute you're fine, and the next, you’re not. In Anne's case, disruption came in the form of a serious medical issue that interrupted her life completely. [...]

Predictive Information Helps Hospital Case Managers

The top 5% of patients, ranked by individual health care dollars spent, are responsible for almost half of the nation’s total personal health care dollars spent. Finding and managing care coordination for this group of patients can be an efficient and effective way to increase quality and reduce total costs for the entire hospital population. [...]

Care at Home Less Expensive than Hospital Care

Three years after the start of the Independence at Home project, more than half (53%) of the participating organizations have been given bonuses ranging from $275,000 to $2.9 million for shrinking Medicare costs and improving patient care. [...]

How To Make Sure Patients Understand Health Information

The success of health system reform will depend in large part on the capacity of individuals, families and communities to make informed decisions about their health. Health literacy is lowest among the more vulnerable members of our communities—those with lower education levels, racial/ethnic minorities, the uninsured and publicly insured, and the elderly. [...]

Riverside Medical Center Case Management Case Study

When a hospital determines to transform its care management program, it takes more than new job descriptions and work flow activities. It takes a change in culture driven by the executive sponsors to embrace a team philosophy to manage the patients progression of care. This is how Riverside did it. [...]

UR and CDI - They Go Together

Should CDI and UR continue to be separate roles when both are reviewing the very same documentation? As hospitals are looking for ways to improve efficiencies, it may be time to consider an integrated role. [...]

Bundled Payment for Observation Care

The FY2016 OPPS proposal includes bundling all observation services. Providers will have to re-think what services are essential to determine the patient's need for acute care hospitalization and to avoid spending more than the anticipated payment of $2011. We urge hospitals and medical staff to rethink the value of evidence based protocols for the high volume observation population. [...]

Directing Admitting Traffic

There is no one 'best practice' defining the role of the admitting hospitalist, but there does seem to be some role features that are encountered more than others. [...]

MSPB - The New Value Proposition

As part of their advocacy role, the hospital case manager is best positioned to influence physician practice behaviors once hospitals learn to create knowledge out of data. [...]

A Change in Culture to Improve Discharges

Healthcare reform continues to pick up steam. The changes in reimbursement and the introduction of new incentives bring continued uncertainty and anxiety for healthcare providers, patient and families, and healthcare leaders. Everyone hears that the changes are meant to bring about high quality care at the lowest price. But the question on the minds of everyone is how will this be accomplished? [...]

The Patient Navigator

Many compelling organizational issues have recently surfaced making the case for a change in hospital case management purpose and operations. It’s a change in the marketplace that signals a change in the role of the case manager from discharge planner (DCP) and utilization reviewer (UR) to that of THE PATIENT NAVIGATOR to advocate for the patients while helping them navigate the progression the ca [...]

The New Knowledge Worker

Hospital care managers need excellent communication skills, negotiation skills, a basic understanding of the psychology of human behavior, agile and creative thinking skills to handle intricate patient and physician interactions, and knowledge of hospital operations to help the patient navigate through the system and beyond. [...]

Preparing for the Future

In the often cited science experiment, when a frog is placed in a pot of scalding hot water, it will immediately jump out. But if the water is cool and heat is gradually applied, the frog will stay in the pot until it is ultimately boiled. This experiment underscores the danger of gradual change. [...]

Here We Go Again

"Here we go again." That was one case manager's reaction when she learned that the case management department would be reorganizing itself to move to an 'outcome-oriented' practice model. [...]

DRIP Systems vs Information Systems

No matter what information system your hospital uses, it produces data.....lots of data.....more data than you can possibly imagine....and more data than you can probably use. There's only one snag: Hospitals are still having a hard time converting the data into information. We call these facilities DRIP organizations: Data rich, information poor. Without information, hospital executives, depa [...]

Organized care and information sharing

From the AHRQ (2015),care coordination is the"deliberate organization of pt care activities & info sharing among all the participants concerned with a patient’s care to achieve safer and more effective care." The CCMC states that a care manager facilitates care resources throughout the continuum "while ensuring that the care provided is safe,effective,client-centered, timely,efficient,& equitable. [...]