As one of the elements of health care reform, The Centers for Medicare and Medicaid Services (CMS) has implemented a course of action aimed at bringing Medicare to a break-even budget.The elements that we are now familiar with include the ‘clinical processes of care’, ‘outcomes’ (which include readmissions, deaths and complications), ‘the patient experience of care’, and now the “efficiency measure”. The “Spending per Medicare Beneficiary Measure” or the ‘efficiency measure’ brings much of the work of case management to the surface yet again. This measure focuses on length of stay and spending per a beneficiary episode, two elements that case management plays a critical role in controlling and managing.
Medicare’s purpose in applying this measure is to encourage hospitals to be more cost efficient by providing financial incentives to hospitals based on their performance.CMS also hopes to increase the transparency of care for consumers and recognize hospitals that are involved in providing high quality care at lower cost.
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”.