Case Managers: On the Frontline for Readmissions

With hospitals three-quarters into their first year of Medicare’s readmission penalty program, administrators are exploring all avenues to help to curb potentially costly withholding of reimbursement. Case managers are proving to be allies in the effort.

Bringing results

Last October, the Centers for Medicare & Medicaid Services (CMS) launched a program that penalizes hospitals for higher-than-expected 30-day readmissions for heart failure, acute MI and pneumonia. The 1 percent penalty will jump to 2 percent in October and then to 3 percent in 2014. Heart failure, with 30-day readmission rates of up to 25 percent and total costs projected at $32 billion in 2013, ranks high on many lists for improvement (Circulation 2013;127:e6-e245). One approach is to better coordinate the transition from hospital to home, with case managers as liaisons.

Moving the dial on outcomes for heart failure patients is a real challenge, says Patricia M. Gorman, RN, administrative director case management at Indiana University Health Ball Memorial Hospital in Muncie, Ind. At Health Ball Memorial, case managers—which can include social workers or nurses—facilitate patients’ successful transition from admission to discharge and work to keep these patients on track clinically.

Case managers use two transitional care models, depending on where patients are in managing their disease. One method is a clinical approach in which case managers help patients deal with their own goals, while the other focuses on training patients to take control of the disease management process.

They offer coaching up to four months after discharge. “The overall trend is coming down,” Gorman reports on all-cause heart failure readmissions. The rate dropped from 25 percent in July 2011 to 20 percent in March 2013.

Meanwhile, at the Heart Failure Center at the University of Connecticut Health Center in Farmington, director Jason Ryan, MD, says its case management program has helped bring down readmissions from 27 percent in August 2010 to 19 percent in March 2012.

The program utilizes a team-based approach, involving social workers and case managers, that works to remove barriers for heart failure patients managing their condition after discharge. Follow-up appointments, linkages with dieticians, pharmacist involvement, collaborations with community providers and cutting-edge educational videos with families and patients all play a part in the center’s care coordination plan.

At the 88-bed William S. Middleton Memorial Veterans Hospital in Madison, Wis., a federally funded 18-month pilot succeeded in reducing readmissions at a low cost. In the Coordinated-Transitional Care Program (C-Trac), registered nurse case managers targeted high-risk patients with post-discharge phone calls. The most common diagnosis of this group was chronic heart failure.

The effort led to one-third fewer readmissions and a cost avoidance of $1,225 per veteran enrolled during the length of the pilot. Although the federal funding ended, the program continues as “it is more than able to cover the costs,” according to Amy Jo Haavisto Kind, MD, PhD, director of C-Trac.

Coordinating care

“We’re good with the admissions process, but we have not done as much with discharge. We have not been as strongly dedicated,” says Gorman. “Patients just want to go home; there is lot of pressure to get them out.”

Health Ball Memorial is changing that by placing increasing emphasis on care coordination. 

Following discharge, case managers call patients three times a week during their first two weeks. If dietary problems are suspected, the managers go to the patients’ homes to review food restrictions and labels. “We’ve gone to restaurants and grocery shopping with patients,” she says, adding that case managers will accompany some patients to the doctor’s office.

Gorman says heart failure patients tend to readmit soon after discharge or closer to the 30-day mark. To prevent that from happening, the case managers refer the patients to their primary care physicians and coach them every week until they are stable.

“We’re extending touch points along the continuum,” says Gorman.

At the veterans hospital, patients opting into the C-Trac program receive a post-discharge phone call within 48 to 72 hours to ensure an active plan for a medical follow-up is in place. “We treat the phone calls like a clinical visit,” Kind says, noting that conversations average 36 minutes. For patients with cognitive issues, the case manager speaks with a loved one or caregiver. Patients are asked to pull out prescription bottles and verbally explain their regimen to ensure proper medication management, she says.

Kind says that because patients reside in rural areas, phone calls are more cost effective than home visits. Also, while she supports home visits, she says patients often find them intrusive and prefer phone calls. The benefit of phone calls is that “we can care for many patients,” she says.

At the Connecticut center, case managers give heart failure discharge patients a follow-up appointment within one week. “Our social workers and case managers spend time talking to them about the services they need,” says Ryan. Medication affordability issues are addressed at this time, too.

Education plays a huge part in the discharge process. In fact, with federal funding, staff developed an evidence-based educational video series to guide healthcare providers, patients and their families in managing heart failure. The videos are “very popular and fill an unmet need,” he says.

Confronting obstacles

Gorman cites a recent internal study at Health Ball Memorial that compared 55 patients’ medication reconciliation lists at the doctor’s office, hospital, primary care physician and pharmacy. Only one out of the 55 patients had a complete match. “It’s distressing to think that we’re all healthcare workers and we’re all trying to do the right thing, except we are doing the right things in silos and nothing matches,” she remarks.

Gorman says a challenge is “how to sustain a program not funded, during a time when you don’t know where things are going to go.” However, in the face of federal penalties, hospitals are finding cost-effective and creative ways to deploy case managers to bring down heart failure patient readmissions.

That means getting everyone working together to care for patients, even after they leave the hospital. Successful providers find that integrated care coordination following discharge not only helps bring down readmissions, but also saves lives.

“One nurse case manager in the C-Trac program saved a person’s life, just by calling,” says Kind.