For patients with cancer, palliative care should begin at diagnosis to help them shoulder the disease’s emotional, physical and financial burdens, explains Laura Ostrowsky, director of case management at Memorial Sloan Kettering Cancer Center (MSKCC). However, for multiple reasons, referrals to hospice frequently happen too late for MSKCC patients to derive full benefit from that service.
In this episode of HealthSounds, Ms. Ostrowsky shares some key questions for integrated case managers to ask providers to improve timeliness of hospice referrals, patient and family satisfaction with hospice service, and awareness of end-of-life care. The strategy is one way MSKCC uses integrated case management to validate its worth in a value-based system: providing the best care in a quality-effective manner.
During Integrated Case Management: A New Approach to Transition Planning, an August 2017 webinar now available for replay, Ms. Ostrowsky outlines MSKCC’s use of a team-based case management model that follows patients as they transition across the health system.
With hospital readmission rates under close scrutiny by CMS, Torrance Memorial Health System launched a readmission program in early 2013 that has been recognized as a program of excellence for its innovation and impact on the community. Navigators work with patients prior to discharge from the hospital to educate them on the hospital’s Care Transitions program, which includes a network of Skilled Nursing Facilities, or SNF’s and one home health agency. And once the patient is discharged, ambulatory case managers keep watch on the patients after the 30-day penalty phase is over.
Josh Luke, Ph.D., vice president of post acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative, shared the key features of the program during Award Winning Readmission Prevention Protocols: Navigating Care Transitions with Preferred SNF and Home Health Providers, a 45-minute webinar on January 8th, 2014, at 1:30 pm Eastern.
There’s education, there’s experience, and then there’s the ‘right stuff’ the indefinable personality traits that earmark an individual as a change agent, collaborator and ambassador of case management, says Annette Watson, senior vice president of community transformation for Taconic IPA (TIPA), of TIPA’s requirements for the RN case managers it hires for its advanced patient-centered medical homes.
Then there are the not insignificant contributions of the RN case manager to accountable and patient-centered care, which Ms. Watson describes in this interview.
While staff-buy-in and communication continue to challenge the embedded case manager model, the participant in CMS Innovation Center’s Comprehensive Primary Care (CPC) initiative says reimbursement for embedded case management is less of an obstacle today than in the past, due to funding-friendly care models and pilots descending from healthcare reform.
Ms. Watson shared how TIPA has successfully embedded case managers in an open, multi-payor community during an October 9, 2013 webinar, Improving Population Health with Embedded Case Managers in an Open, Multi-Payor Community.