July, 2010

BROUGHT TO YOU BY PHOENIX: THE HOSPITAL CASE MANAGEMENT COMPANY

VBP 2011
As a way of emphasizing our comments about the anticipated changes driven by the reform act, next year, Medicare’s value-based purchasing program is going to present significant challenges for hospitals, and by proxy, hospital case managers. The Centers for Medicare and Medicaid (CMS) will be holding back 10% of hospital payments. The top 10% of hospitals that achieve high scores on a composite measure combining core measures, HCAHPS, and readmission rates will receive full payment. The next 40% of hospitals will get a portion of the holdback. The bottom half of hospitals will get nothing and will be losing 10% of Medicare revenue. Pundits predict that many of these hospitals would be forced to close, as they are barely surviving now. With our focus on working with physicians to effectively manage progression-of-care, case managers are strategically positioned to help bring the performance of our hospitals to a higher level. Patient satisfaction, readmission rates, and core measure compliance will be pocketbook issues that will affect everyone.

Book Winners
We would like to offer our genuine thanks to the hundreds of people who attended the special session on Hospital Case Management presented by Phoenix partner, Stefani Daniels. Your reception to the program was overwhelming and your feedback was gracious and appreciated. Congratulations are extended to Erna VanRooyen, from Johannesburg, So Africa, Janet O'Brien from Philadelphia, PA and Sheryl Hiers from Knoxville, TN. These case managers won the drawing for the book giveaways including You Bet Your Life: The 10 Mistakes Every Patient Makes by Trisha Torrey, and a copy of The Leaders Guide for Hospital Case Management by Stefani Daniels and Marianne Ramey. For an overview of Daniels' session, check out Richard Scott's review for Dorland Health Read more

ABOUT US
*PHOENIX is a national consultancy dedicated exclusively* to hospital case management.** Our experts are experienced hospital leaders with very practical insights on the relationship between hospital operations and case management effectiveness. Working closely with members of the C-suite, the medical staff, and the case management team, we're ready to add value with customized deliverables and a hands-on, roll-up-the-sleeves attitude. Our passion for case management excellence has become our firm's defining characteristic and has helped us become the leading firm offering exclusive hospital case management services. Learn more

AND vs DNR
In its special End of Life edition, Case In Point published an article about Allowing natural Dealth (AND) written by Phoenix partner Stefani Daniels and end of life expert Robin Gordon Taft. Unlike the more popular Do Not Resuscitate (DNR) order, AND is a softer approach to open end of life discussions with patients and families and has a modest history of success when used by caring case managers. Click here to check out the digital edition of the magazine. read more

Notes on the CMSA Conference

When we started attending regional and national conferences many years ago, the one presence that we could count on was the pharmaceutical companies. They were there for sound marketing reasons: Increase case managers' and nurses' awareness of their new product in the hope they could push the product to the physician prescriber. Attending one of their so-called 'educational' programs was like watching one TV commercial after another peppered with research studies they sponsored. Objectivity was clearly not a goal. As a result, we routinely avoided any so-called 'educational session' sponsored by the pharaceutical industry.

But times change! At this year's CMSA conference which drew over 1700 attendees in Orlando, FL, your editors attended several educational sessions underwritten by pharmaceutical companies. Unlike days gone by, these programs were informative, free of commercial intent, and relevant to clinical practice of any provider. The sessions we attended provided the latest treatment options and insights into future research which were truly enlightening.

That was the good news. On the down side, there was a paucity of sessions related to hospital case management practice. Nothing about the current RAC status, the anticipated changes in hospital reimbursement, updates about some of the demonstration projects such as CARE and ACE, nor any word about the ICD-10 changeover and its potential implications for hospital case managers. There was a representative from CMS in the exhibit hall, but he was gone the second day and there was no one presenting to give an update on the impact of the reform act. This is a serious gap in CMSA outreach efforts and one, which we hope, they will remedy.
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Healthcare Financial Mgmt Assn ANI

HFMA is the leading membership organization for healthcare financial managers and at this years Annual National Institute, held in Las Vegas, we noted a single recurring theme: Hospital efficiency! While the sense of financial concern was absent at CMSA, at the ANI it was palpable! Under the new healthcare reforms, everyone at ANI was talking about what hospitals had to do to gain greater efficiency.

Hospital case managers walk both the clinical and financial halls of the hospital and they know that financial issues have long been of concern among acute care providers. We're also pretty sure that they realize that the new reforms have implications that will affect their practice. Reform will expand the number of insured by an estimated 32 million citizens, half of whom will be covered by Medicaid through the massive expansion of the program. Payment will follow quality and efficiency and will be bundled with payments for physicians. Measures to reduce reimbursement for preventable readmissions are being put in place. Creation of accountable care organizations, which many pundits consider code for the re-introduction of full capitation, will further limit reimbursement. And be assured that the reform bill will significantly amp up the amount of required reporting.

If you are still practicing under the traditional functional model of hospital case management (UR & DCP), reform means that you are going to feel even greater pressure to reduce LOS since length of stay remains the dominent, albeit flawed, metric in most hospitals. We also think you will see greater use of physician profiles to objectively review how physicians are using resources compared to their peers caring for similar patient populations.

If you are practicing under a progression-of-care, outcome model, it means that your partnership with the physician and the clinical team will take on additional importance. Coordinating care, collaborating with physicians, using evidence based protocols, efficient communication within the team, ensuring proper patient hand-offs, post acute follow-ups, and coaching for accurate documentation are the ways hospitals are going to survive in the new environment. If you don't have that kind of care efficiency, supported by up-to-date technology, the hospital won't be able to stop the cost inflation. The reality is with no margin, there is no mission!
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Transitions of Care

One of the hot topics at both the CMSA and HFMA conferences was care transitions interventions. Hospital execs recognize that you can't run away from Medicare which accounts for upwards of 37% of hospital admissions and 50% of hospital bed days. We learned that several hospitals currently participating in the ACE program are looking to expand the participating patient populations. They know that they have to work with these predominently Medicare patients without losing their shirts. Hospital sponsored ToC interventions run the range of activities from routine post-discharge phone calls to home visits by community based case managers. While many hospitals are underwriting the costs of these innovative programs, many are seeking grants in the hope that these programs will reduce the revolving door of readmissions.

Many hospitals, we found, are re-thinking the benefits of palliative care and geriatric programs. Senior patients with challenging, often chronic conditions, are making up an increasingly significant portion of the hospital population and their care is complex and expensive. Senior care used to be considered a cost center, but turning it into a profit center may now be possible. In fact, Johns Hopkins in Baltimore and Mount Sinai in New York recently launched a pilot program to spread the idea of quality senior care. The grant-funded Medicare Innovations Collaborative, www.med-ic.org, is implementing new geriatric models of care aimed particularly at community based hospitals.

All of these initiatives remind us of a young, newly minted hospital CEO we met several years ago. He told us that until hospitals change their mission from caring for hospitalized patients to caring for the community, hospitals will continue to be financially threatened. It seems his prescient thinking is finally hitting the front pages. This is the time for hospital case managers to step forward to help these patients and their families with the knowledge and skills they need after an acute care episode and to make sure that the transition of care is safe, appropriate and in the patient's best interest. That's what advocacy is all about!

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