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The Centers for Medicare and Medicaid Services (CMS) has instituted linkages between cost and quality through value-based purchasing and other cost-saving measures such as payment penalties for high readmission rates. These changes have created the first links between the cost and quality of health care. These factors now require that case management models begin to change and adapt. The early case management models no longer meet the needs of the changing healthcare landscape!  It is for this reason that hospitals and healthcare systems must look thoughtfully and carefully at the design of their case management models, the roles used, and the staffing ratios of their case management departments.

No hospital can afford to remain stagnant in an environment that seems to be changing at a lightning pace.  While the Medicare programs had remained fairly constant for many years, CMS now routinely changes the penalty and reimbursement structure in addition to adding new expectations such as the Two-Midnight Rule, and other similar rules and measures.  Nevertheless, it seems that the case management department often seems to be the last department to be updated or enhanced to meet the new challenges imposed by the Affordable Care Act and Value-Based Purchasing.

Selection of the most appropriate model will depend on the needs of the organization, the available resources, and the expected goals and outcomes. Each case management department should ensure that they have correct roles, functions, and staffing ratios. This program will provide you with the tools that you will need to identify the changes or upgrades you may need to make in your own case management department.

This program will review contemporary, best-practice, case management models. The program will begin with the contemporary case management roles used in hospitals today. This will be followed by a model review which will include descriptions of the two most commonly used models, the key differences between the models, as well as how they should be designed and structured. This will be followed by the pros and cons of each model and how the department might be designed to accommodate each model.  The best practice staffing ratios for each model will be discussed as they apply to the roles of the RN case manager and the social worker as well as strategies for optimizing existing resources.

The program will conclude with a discussion of the steps needed to re-engineer a case management department and tips for identifying the best model for your organization.