Q&A: How Case Managers Can Grapple With Readmissions

[Richard Scott]

What advice do you have for case management departments that want to start contributing to better readmissions and, likewise, promote their value?

[Susan Plough]

Look at your data to see where your opportunites for improvement are. Next, engage your team, including nursing, physicans, clinical nurse specialist,and Administration. We also had our partners in Home Health, Rehab, LTACs and SNF's at the table with us to devise strategies around readmissions.

[Richard Scott]

Wonderful insight. For other case managers out there, this website serves as an open forum where you can discuss readmissions, strategies, obstacles, and other related topics. We look forward to hearing from you!

As far as resources go, here is some reading material to get you started:

6 Lessons for Reducing Readmissions: How 4 Hospitals Are Excelling
http://www.dorlandhealth.com/case_ma...tice/1775.html

7 Steps for Robust Discharge Planning (and Reduced Readmissions)
http://www.dorlandhealth.com/case_ma...ions_1790.html

Reducing Readmissions: A New Sense of Urgency
http://www.dorlandhealth.com/case_ma...ends/1683.html

Susan - any parting words or resources you would like to share?

[Susan Plough]

We are all walking down the same path but remember... case mangers are leading the way with this struggle. I encourage every one to use the resources that Richard is offering us and engage your team. We are in an uncertain but exciting time in healthcare and keeping our patients at the center of what we do will serve us well. I am happy to share what we are doing in detail with anyone who would like to contact me. We have much work to do and no time to reinvent the wheel Good luck.

[Anne Llewellyn]

Susan, has your leadership offered resources that will allow you to follow the patient beyond the walls of the hospital? I think most avoidable readmissions occur as a result of the patient not unerstanding discharge instructions and not having someone to call to ask questions. Organizations who have implemented transition of care programs that provide follow-up for patients once home have shown positive results. Models such as this include; the Guided Care Program, http://www.guidedcare.org, Eric Coleman's Transition of Care Program http://www.caretransitions.org and Mary Naylor's New Corltland Transition of Care Program http://www.innovativecaremodels.com/...els/21/leaders are leaders in this process.

[Stefani Daniels]

Hospitals will have to invest into more assertive post acute follow up than a phone call. The cost:benefit will support the investment to counteract potential penalties. Case manager transitionists provide hands-on follow up among selected high risk patients. Duke U conducted a demonstration project with outstanding outcomes but backed out due to cost. Myopic perspective if you ask me. Perhaps new incentives will get it back up and running.

[Richard Scott]

Let's hope that incentives do force the issue. As another resource, I will share the recap of the latest Case In Point Webinar, featuring CMS Team Lead Juliana Tiongson, that focused on readmissions, transitions and discharge planning. Here's the recap:

http://www.dorlandhealth.com/case_ma...tice/1806.html

And here's a link to the learning program:

http://www.dorlandhealth.com/webinar..._readmissions/