by Stefani Daniels, President and Managing Partner
Published on Jul 14, 2016

Every day, the reality of the changing healthcare marketplace is more present and visible. From the movement away from payments based on volume and new bundled payment models to heightened expectations for greater safety, quality, and patient engagement, the need to anticipate, prepare and adapt to the healthcare marketplace has never been as clear. Hospital case management programs have a key role to play in supporting stakeholder resilience to marketplace impacts and a responsibility to advocate excellence.


While many hospitals have case management programs in place today, few leaders have evolved their programs to be able to tightly measure and manage outcomes. And outcomes is what contemporary hospital case management is all about.

Unfortunately, too many hospital leaders have preserved the task orientation of 2nd generation hospital case management programs. These programs are generally focused on completing activities related to utilization review and discharge planning for the entire acute care population and are heavily dependent upon chart review activities with minimal care manager visibility to the patients, the physicians, and the healthcare team.  

"It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change."  

When considering the ever-evolving healthcare industry, Charles Darwin's quote couldn't ring more true.  With the impending move from volume (FFS) to value-based (outcomes) payment models, hospital case management programs - from small critical access hospitals to large academic teaching facilities - must re-evaluate how they manage case management's multiple activities.  Case management program leaders must adapt how they organize and manage progression-of-care, care coordination, utilization review, resource management, and discharge planning for selected high risk patients to engage in collaborative practice models that are patient centric across the continuum of care.

Adaptation offers many opportunities and benefits.  A well structured care coordination approach can use predictive analytics to identify high risk patients who would benefit from the care coordination skills of an acute care manager;  patients would have a single consistent resource as their advocate as they navigate through an episode of care;  hospital leaders would see a reduction in length of stay and costs resulting from ensuring that the medical interventions ordered meet the patient's and family's preferences, are not wasteful, excessive or potentially harmful, and are supported by evidence based protocols;  and physicians would have a coach and advisor at the point of care to help them document accurately to reflect their medical judgment and protect them, the patient and the hospital against financial risk.

Other benefits include a fine-tuned access management program with highly skilled, proficient utilization review specialists as the resident experts on all compliance matters regarding medical necessity as dictated by federal regulations and contractual obligtations.  There would be a centralized post acute resource center to mobilize activities to facilitate the logistics of post acute services and there would be transitional care to address the needs of vulnerable patients in the community. 

This ”responsible” case management adaptation, focused on creating shared value and enhancing patient centered care, is the most robust approach to mitigating service fragmentation and capitalizing on case management opportunities. Adapting responsibly to the marketplace can also constitute a significant contribution to the implementation of the Triple Aim and strengthen the hospital's resilience and adaptive capacity to the new marketplace. 

Hospital case management adaptation to keep up with the changing marketplace is not an option - it is essential to fulfill its professional  mandate.