Oct. 13-19 is National Case Management Week. Case managers play an integral role in our health-care delivery system. They act as advocates, educators, navigators and resource managers, helping patients understand and manage their condition, find and gain access to services, and obtain high-quality, cost-effective care.

We often hear about the high cost of medical care and the uncertain times many hospitals are facing because of financial insecurity. There are many reasons that contribute to high-cost care, but many can be directly related to poor transitions and lack of effective discharge planning, which result in increased readmissions. Other causes that create financial uncertainty for hospitals are related to the use of hospital services and the increasing rigors required to meet the expectations of commercial, state and federal insurance plans. An additional factor is lack of patient engagement, understanding of, and commitment to, their prescribed plan of care.

Thankfully, Rutland Regional Medical Center has committed and engaged case managers, utilization managers and transitional care to tackle the complexities of discharge planning, utilization management, patient-care coordination, partner collaboration, resource management and patient education.

Case managers are tasked with developing meticulous discharge care plans for complex patients. It is more difficult in 2019 than it was several years ago because of the complex acute conditions and number of increasing comorbidities of our community. An additional factor that adds stress is the time factor. The average length of stay is decreasing for our acute medical and surgical patients. Thankfully, we have our transitional-care team that follows some patients from the acute-care setting to the community setting. They visit the patient in the home or health-provider office to continue the care coordination, patient education and support to assist with patient engagement and adherence.

Then there are those who work quietly in the utilization department. The utilization nurses work with numerous internal and external customers to ensure appropriate utilization of services and payment for the services rendered at Rutland Regional. Utilization managers review the charts of all patients admitted to the hospital to make sure they are admitted to the correct level of care, that there are appropriate orders and physician and nursing documentation to support the care level and, if required, that prior authorizations are in place to prevent insurance denials. The responsibilities are increasing due to the stringent nature of commercial, state and federal insurers. Unfortunately, we are seeing an increase in volume of denials which requires increasing effort and responsibility by the Appeals and Denials Team to mitigate the risk to the financial health of Rutland Regional.

Our case management team is dedicated, committed and passionate about working with patients and families in these endeavors. These things make a tremendous difference in their lives and in our health care system.

This week’s Health Talk column is written by Kathleen Boyd, director, MSN, RN, RN-BC, CCM, case management, utilization management, transitional care, CDIS, hospital medicine, Rutland Regional Medical Center. www.rrmc.org

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