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Value-based purchasing is in full swing and with it the complexities and challenges of offering higher quality and more cost-effective care than ever before, in order to afford both greater patient care outcomes and favorable reimbursement for healthcare services. As the focus and reality of joint accountability for providers and physicians sets in, and smooth patient care transitions between providers and care settings becomes imperative, community healthcare leaders have come to the realization the days of operating in a silo are gone, and a team-based delivery system is now the standard by which we all need to operate.

 
In this new system of accountable care, case managers find themselves at the forefront of facilitating greater collaboration amongst providers who have been accustomed to substantial autonomy. “The scope of the case manager’s role has grown. We can no longer only evaluate the data related to the inpatient stay; today’s case manager has to proactively reach out to the pre and post-hospital providers more than ever before to exchange information in order to achieve better continuity of care for our patients.” With this, the opportunity is there for case managers to help close the large gaps in transitions of care that exist in healthcare today.
 
With the discharge phase of hospitalization being an area of focus in may Transitions of Care projects, case managers are challenged with developing discharge plans that are not only comprehensive but incorporate best practices in order to reduce hospital readmissions, one of the focus areas of Value-based purchasing. We must strive to continually improve our discharge processes to ensure patients are well-educated and are linked to available resources to maintain optimum health and avoid unnecessary returns to our emergency departments. As a member of the steering committee of the Broward County Community Coalition to reduce readmissions, it is exciting for me to work with other healthcare providers from a variety of settings to develop best practices. Our current project focuses on the medication reconciliation process, which is a very important component of discharge planning and care transition.
 
The financial pressures related to Value-based purchasing are only one example of the pressures facing hospitals and health systems today. The implementation of the Recovery Audit Contractor (RAC) review and associated denials has also had a negative impact on the bottom line of many hospitals. To make matters worse, commercial payers are following suit and developing their own programs. All of these programs and audits put hospitals at financial risk as the stringent requirements and expectations related to medical necessity documentation for inpatient level of care are audited like never before. This places case management departments in a unique position to demonstrate their value with the revenue cycle process, as case managers are responsible for ensuring all the documentation requirements are met and the role of educator becomes increasingly important. Case management departments have to remain flexible and adopt or change current processes to respond to the rigid demands and scrutiny of both government and non-government payers. At each phase of the acute care experience, from pre-admission to post-discharge, the case manager is tasked with activities aimed at ensuring timely and appropriate reimbursement of hospital services.
 
To that end, having a robust Denial Management program becomes increasingly important. The goals I have established for our committee are two-fold – first, review denied claims, and perform root cause analysis to identify trends and opportunities to improve front-end processes, and second, develop a strong appeals program to respond to medical necessity denials in timely fashion and hopefully reverse the denial. All of this can be time-consuming but it is definitely time well spent and rewarding when you see the dollars come in on previously denied claims, and knowing this effort has a direct positive impact on the bottom line.
 
With all of these challenges, it is imperative to build a solid case management team who can execute the functions of utilization management, discharge planning, and care coordination in a disciplined fashion. The role of the hospital case manager can be quite complex and it can take a year or more in some cases for new hires to feel completely comfortable and confident in their role. It is up to the leaders of case management to not only build strong training programs, but also place an increased focus on employee retention in order to stay ahead of the game. Considering the rapid pace of change in healthcare today, and all of the financial pressures we face, we literally can’t afford to do otherwise.