The Centers for Medicare and Medicaid Services (CMS) has instituted linkages between cost and quality through value-based purchasing and other cost-saving measures such as payment penalties for high readmission rates. These changes have created the first links between the cost and quality of health care. These factors now require that case management models begin to change and adapt. The early case management models no longer meet the needs of the changing healthcare landscape ! It is for this reason that hospitals and health care systems must look thoughtfully and carefully at the design of their case management models, the roles used, and staffing ratios of their case management departments.
This program will review contemporary, best practice, case management roles and models. The program will begin with the contemporary case management roles used in hospitals today. This will be followed by a model review which will include descriptions of the two most commonly used models, the key differences between the models, as well as how they should be designed and structured. This will be followed by the pros and cons of each model and how the department might be designed to accommodate each model. The best practice staffing ratios for each model will be discussed as they apply to the roles of the RN case manager and the social worker as well as strategies for optimizing existing resources.
The program will conclude with a discussion of the steps needed to re-engineer a case management department and tips for identifying the best model for your organization.
No hospital can afford to remain stagnant in an environment that seems to be changing at a lightening pace. While the Medicare programs had remained fairly constant for many years, CMS now routinley changes the penalty and reimbursement structure in addition to adding new expectations such as the Two-Midnight Rule, and other similar rules and measures. Nevertheless it seems that the case management department often seems to be the last department to be up-dated or enhanced to meet the new challenges imposed by the Affordable Care Act and Value-Based Purchasing.
Selection of the most appropriate model will depend on the needs of the organization, the available resources, and the expected goals and outcomes. Each case management department should ensure that they have correct roles , functions and staffing ratios. This program will provide you with the tools that you will need to identify the changes or upgrades you may need to make in your own case management department.
Toni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating acute care and community case management models, providing on-site education to case management staff, and strategies for assisting health care organizations in improving their case management department’s efficiency and effectiveness.
The author of nine books, and a frequently sought after speaker, lecturer and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management.
Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management.
Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York. She was responsible for case management, social work, discharge planning, utilization management, denial management, bed management, the patient navigator program, the clinical documentation improvement program and systems process improvement. Prior to her position as Senior Vice President at Lutheran Medical Center, Dr. Cesta has held positions as Corporate Vice President for Patient Flow Optimization at the North Shore – Long Island Jewish Health System and Director of Case Management, Saint Vincents Catholic Medical Centers of New York, in New York City and also designed and implemented a Master’s of Nursing in Case Management Program and Post-Master’s Certificate Program in Case Management at Pace University in Pleasantville, New York. Dr. Cesta completed seven years as a Commissioner for the Commission for Case Manager Certification.
Dr. Cesta has presented topics on case management at national and international conferences and workshops. Her books include “Nursing Case Management: From Essentials to Advanced Practice Applications”, “The Case Manager’s Survival Guide: Winning Strategies in the New Healthcare Environment”, “The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice”, “Survival Strategies for Nurses in Managed Care” and “Core Skills for Hospital Case Managers”.