Archive for April, 2012

CMS Proposes Increased Hospital Fees for Improved Patient Care

April 30th, 2012 by Cheryl Miller

Hospitals are getting a raise, of sorts. CMS has proposed a rule that would update Medicare payment policies and increase rates for inpatient stays at general acute care and long term care hospitals. The ruling, if finalized, is designed to strengthen patient care and promote quality over volume, CMS officials say. Included are quality measures regarding hospital-acquired infections, and a new HCAHPS survey measure regarding care transitions. Public input will be accepted until June 25th.

Care transitions is the subject of a new report from Avalere Health for the Alliance of Community Health Plans. It proposes five ways to enhance the transition from hospital to home. Among them: engaging patients early on in their transition period, prior to discharge, and encouraging providers to become program partners. Health systems whose transition programs are perceived favorably are also mentioned in the report; details in this issue.

The chronically ill are the target of a new Commonwealth Fund report, which seeks to launch a care plan over the next 12 months in 50 to 100 communities around the country that have significant concentrations of patients with multiple chronic conditions and high medical costs. Such a plan could save $184 billion in health spending over the next 10 years, commission officials say.

Text message reminders to parents about flu vaccinations may help boost the number of children vaccinated, according to a recent report from Columbia University Medical Center and New York-Presbyterian Hospital. Texting is considered an effective tool given its ability to reach large numbers of people, researchers say. The study focused on hard-to-reach, low-income, urban children and adolescents, because they are more at risk for acquiring influenza due to their crowded living conditions. And while a higher percentage of families receiving the message did vaccinate their children, overall, vaccination rates remain low.

This might be good news to a group of Vermont-based residents advocating against a law that would make vaccinations in their state mandatory. According to a recent story from ABC World News the debate over the bill has divided Vermont's families over the benefits and risks of vaccines. It has also pitted the state House — whose majority voted down the bill — against the state Senate, which voted to approve it. The debate will most likely continue, lawmakers say.

And lastly, if you haven’t already, please take part in our second annual Accountable Care Organizations survey. The last 12 months have been a hotbed of ACO activity. In addition to the many private pilots of this collaborative care model, CMS kicked off its Medicare Shared Savings Program on April 1st. Participants get a FREE executive summary of the compiled results and year-over-year ACO trends.

These stories and more in this week's issue of Healthcare Business Weekly Update.

New HCAHPS Measure Would Evaluate Quality of Care Transitions

April 27th, 2012 by Patricia Donovan

Beginning in January, patients discharged from the hospital could be asked three key questions to assess the quality of their care transitions, as part of a proposed new measure in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey.

As part of a proposed rule issued April 24, CMS wants patients about to be discharged to respond to the following three statements about the care transition:

  • During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my healthcare needs would be when I left.

  • When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.

  • When I left the hospital, I clearly understood the purpose for taking each of my medications.

For the last question, patients would be able to indicate that they were not given any medication at discharge.

The proposed questions are based on the three-Item Care Transition Measure developed by the University of Colorado Health Sciences Center for the NQF Endorsement Project entitled “National Voluntary Consensus Standards for Quality of Cancer Care.” Detailed information on scoring methodology can be found on the Care Transition Measure Web site.

CMS also wants to add two "About You" items to the survey that would not be included in public reporting of the HCAHPS survey but would be employed in the patient-mix adjustment:

  • During this hospital stay, were you admitted to this hospital through the Emergency Room?

  • In general, how would you rate your overall mental or emotional health?

CMS said it has received numerous inquiries and requests from hospitals and researchers to add a survey item concerning patients' overall mental health. Some researchers claim that mental health status is an important factor in how patients respond to HCAHPS survey items.

The HCAHPS Hospital Survey is a standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care. In its current form, the HCAHPS survey contains 18 patient perspectives on care and patient rating items that encompass eight key topics: communication with doctors, communication with nurses, responsiveness of hospital staff, pain management, communication about medicines, discharge information, cleanliness of the hospital environment, and quietness of the hospital environment.

The survey also includes four screener questions and five demographic items, which are used for adjusting the mix of patients across hospitals and for analytical purposes. The current survey is 27 questions in length.

27 Questions to Ask to Prevent Heart Failure Readmissions

April 27th, 2012 by Jessica Fornarotto

Was aspirin prescribed for the patient?

Asking this simple question and 26 others on a one-page checklist can help to prevent heart failure readmissions and in the long run reduce billions in Medicare healthcare spend each year, according to new research presented by the American College of Cardiology (ACC).

The ACC determined that the checklist made it possible for clinicians to cut the percentage of patients who were readmitted to the hospital within one month of a cardiac event from 20 to just 2 percent.

The readmission rate continued to be lower six months after discharge.

This checklist, developed by Dr. Abhijeet Basoor at St. Joseph Mercy Oakland Hospital in Pontiac, Mich., where he practices internal medicine and cardiology, was instituted after approval of the hospital Cardiovascular Quality Integration Board.

According to Dr. Basoor, everything on the checklist is derived from and reinforces evidence-based practices for managing heart failure and lowering the likelihood of another cardiac event.

The checklist is divided into three parts:

  • medications and their appropriate dose modification;
  • counseling and monitoring intervention; and
  • follow-up instructions.

The average heart failure patient will need 12 to 15 of the total 27 interventions listed, so using this checklist can help remind both patients and doctors about the various steps that can be taken to manage the condition, Dr. Basoor added.

"The checklist provides simple reminders to instruct patients about things like diet, weight, blood pressure monitoring and appropriate drug dose up-titration,” said Dr. Basoor. "The physician or nurse practitioner working with the patient uses the checklist, so hospitals don’t have to pay for additional nursing staff or home care follow-up."

According to Dr. Basoor, "In addition to lowering 30-day and six-month readmissions and the associated costs, we also showed that more patients in the checklist group were likely to be on correct medications and had appropriate drug doses than patients in the control group."

For this new study, 96 heart failure patients were followed for six months after discharge for an initial cardiovascular event. Doctors randomly used the checklist before discharge in half of these patients, while the other half received standard treatment including discharge education and instructions. Data were collected at 30 days and six months post-discharge. Both groups were comparable in terms of other cardiovascular risk factors, age, sex and physician groups treating them.

After excluding deaths during follow-up, only one person in the checklist group was readmitted to the hospital in the month following discharge compared to nine in the control group. At six months, 11 patients in the checklist group had been readmitted, compared to 20 in the control group. Higher proportions of patients were on ACE I/ARB medications (those used to control blood pressure) in the checklist group compared to the control group (40 of 48 vs. 23 of 48, 95 percent CI = 0.17 to 0.53, p < 0.001). Compared to the control group, the rate of dose up-titration for beta-blockers and/or ACE I/ARB was significantly more common in the checklist group (21 of 48 vs. four of 48, 95 percent CI = -0.5 to -0.19, p < 0.001). "Right now the checklist is not part of the standard medical record, so there could be resistance to using it," said Dr. Basoor, "but if we show it’s really beneficial and easy to use, this could become a common practice. We’ve shown that quality of care can be improved at almost no additional cost. In the era of electronic medical records, we are working on transforming the checklist to an electronic form." While other studies have shown that home care and patient education can reduce readmissions, this is the first to evaluate the use of such a unique one-page, in-hospital checklist that required no extra cost. According to the Kaiser Family Foundation, heart failure readmission costs $12 billion in Medicare spending each year and approximately 25 percent of Medicare patients with heart failure are readmitted to the hospital within 30 days of an event. Previous studies have shown 50 percent of these heart failure readmissions can be prevented. When the Affordable Care Act takes effect in 2014, Medicare will begin to penalize hospitals with high readmission rates by refusing reimbursements.

Meet Healthcare Case Management Manager Barbara King: Nurses Key to Reinterpeted Vision of Case Management

April 26th, 2012 by Cheryl Miller

This month we provide an inside look at a healthcare case management manager, the choices she made on the road to success, and the challenges ahead.

Barbara King, BSN, RN, Co-Founder and President of NurseValue, Inc.

HIN: What was your first job out of college and how did you get into case management?

Barbara King: My first position was as a nurse, working the night shift on a 33-bed male urology unit. My fondest memory: an elderly man with a TURP (transurethral resection of the prostate) that had clotted. I entered the room prepared to irrigate his catheter, knelt beside the bed, and explained the procedure to the patient. He stopped me and said, “Please go get the real nurse, you look too young to be a nurse.” I explained that I was the ONLY nurse and he did finally agree to allow me to clear his catheter.

I spent many years in various nursing positions before I fell into the role of case management. I had grown tired of nursing and felt that the lack of staffing would eventually lead to an error that I did not want to make. I tore up my nursing license and took a position outside of the nursing field. A short time later a friend from a staffing agency called and asked me to fill an open position. She described a telephonic case management position to me. She overcame my protests of ignorance and I reported to work as a temporary employee for an insurance company that was rolling out one of the first telephonic case management pilot programs in the country. My friend at the staffing company told me just to listen, follow directions and keep quiet. She assured me that I could do the job. I received a superb orientation and began working as a telephonic case manager. I loved the work and was assured by my manager that I would soon be hired. The next thing I knew I was the supervisor of the western division of the company handing all corporate accounts. At this point, I went to my manager to ask if they had made a determination about a permanent position. She said, “I thought we already hired you. You have already been promoted.” I was hired that day and found my staffing friend was right. Listen, follow directions, keep quiet and you can do it.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road.

Approximately seven years ago I grew tired of seeing case management interpreted by those who did not really understand the service. Knowing the way I wanted to perform as a case manager, it was time to make a professional change. I resigned from my corporate position on Martin Luther King’s birthday because “I had a dream”. That was the birth of NurseValue, Inc. Yes, I believe nurses have value and so does the population they serve.

In brief, describe your organization.

NurseValue, Inc. offers comprehensive custom consulting services for individuals, attorneys, managed healthcare companies, insurance companies and organizations that require field and telephonic case management, legal nurse consulting, life care planning, disability cost analysis for worker’s compensation, third party medical bill review, and Medicare set-aside allocation services.

What are two or three important concepts or rules that you follow in case management?

  • The number one rule in both business and nursing is to always be honest.
  • Next I would say that the nursing process is useful when providing any service: assessment, diagnosis, planning, implementation, and evaluation.
  • Lastly, continue to learn throughout your career as you never know when that tiny bit of information will help to solve a pressing issue.
  • What is the single most successful thing that your organization is doing now?

    NurseValue provides custom solutions to our clients. Our experience opens the door to complicated case referrals. We then use our understanding of the health system, our knowledge of health, injury and illness, and our collaborative communication process to drive cases to the most successful end point possible. Our clients appreciate the fact that we have developed a successful case management model that combines the telephonic and field case management services in a unique delivery system that provides a cost conscious solution.

    Do you see a trend or path that you have to lock onto for 2011?

    Healthcare is trending toward benchmarking utilizing clinical treatment guidelines. Utilizing benchmarking tools to measure success will become increasingly important to the practice of medicine and nursing.

    What is the most satisfying thing about being a case manager?

    I love so much of this profession it is hard to determine what I like most. I guess, it is most satisfying when the client I am working with reaches full potential and returns to life with the tools to be successful.

    Where did you grow up?

    I grew up in Iowa. I was an Iowa “pig farmer’s daughter”. You can take the girl to the city, but a little bit of country will always remain.

    What college did you attend? Is there a moment from that time that stands out?

    My post-secondary education was completed at the University of Iowa, in Iowa City Iowa. If there was one time in history that I could return to it would be nursing school. So...there are so many fond memories that I could not choose just one.

    Are you married? Do you have children?

    My husband and I have been married for over thirty years. We raised two sons who live out of state and visit whenever they get a free moment in their busy lives.

    What is your favorite hobby and how did it develop in your life?

    My sanity is my gardening. The plants still respond to the nursing process, but they are like babies - they present with silent problems and need a lot of TLC.

    Is there a book you recently read or movie you saw that you would recommend?

    I use to read a great deal of fiction, however now my reading is limited to professional journals. There never seems to be enough time to absorb the ever changing treatment protocols and healthcare regulations.

    Any additional comments?

    Thank you for the opportunity to express my views. When I left for nursing school, my father said, “whether you become a nurse or not, no one can ever take the knowledge away from you.” I don’t believe he realized how prophetic his comment was. Nursing enables us to advocate for our loved ones, our patients (clients), and even strangers that we meet along the way. The opportunities are endless.

    Click here to learn how you can be featured in one of our Case Manager Profiles.

    3 Key Questions to Ask ED Patients to Reduce Utilization

    April 24th, 2012 by Cheryl Miller

    Establishing when a patient first had problems, and when they needed to go to the ED, are two questions that help physicians establish a timetable, a particularly valuable tool with the Medicaid population, who utilize the ED twice as often as their insured counterparts because of primary care access barriers, says Mina Chang, Ph.D., chief of the health services research and program development section of the Bureau of Health Services Research for the Ohio Department of Job and Family Services.

    (Dr. Mina Chang) I try to recommend three questions to ask five patients. The first question is: When did you first start having problems? The second is: When did you first recognize you might need a medical opinion? And the third question is: When did you realize you needed to go to the ED? Those questions are trying to help you establish a timetable. Hopefully it will be early enough so that you can find out how early you can develop a test intervention to address the patient’s upstream issues. This is very relevant for the disadvantaged population, including Medicaid. Those patients oftentimes have social service needs, and those issues may exacerbate to a point that they would have to seek ED care. One of the examples could be transportation.

    Another very typically asked question about our interventions to reduce ER use is whether we need patient consent. The follow-up effort between the healthcare providers and the patient, or the payors between the patients is considered permissible under HIPAA because that will be considered part of the treatment, payment and healthcare operations. And also included later in the test intervention that we developed will be focusing on better coordinating care for the patient as a part of quality improvement. So, that would also fall under the Treatment, Payment and Healthcare Operations (TPO) under HIPAA.

    However, we do recommend that since each institution has a very different review process and requirements, that you involve them early on. We are encouraging participants in the ED Collaborative to have very good knowledge about what’s involved so they can make a very good business case for their internal review team. Also, involve your leadership. Having their commitment and support early on is also key.

    Source: 5 Interventions to Reduce Avoidable ER Use by the Medicaid Population

    Geisinger, Bon Secours and Baptist Among Thomson Reuters’ Top Hospitals Award Winners

    April 23rd, 2012 by Cheryl Miller

    Geisinger, Bon Secours and Baptist Medical Center, all frequent contributors to HIN, have facilities named to the list of top 100 hospitals in Thomson Reuters’ annual study. Determined by publicly available information from such sites as the CMS Hospital Compare Web site, and judged on such factors as patient safety and satisfaction, profitability, adherence to clinical standards of care and readmission rates, the top 100 facilities were selected from nearly 3,000 short-term, acute-care, non-federal hospitals.

    Those readmission rates may be misleading, however. According to a new report from the UCSF Medical Center, publicly reported all-cause hospital readmission rates include scheduled readmissions and readmissions that have nothing to do with the original admission. This finding is particularly troubling for spinal surgeons, who often have to stage multiple surgeries to ensure safety and healing. Researchers hope the inaccuracies, which can affect hospital ratings and public perception, don’t adversely affect surgeons as well. More in this issue.

    Also publicly available is a new consumer assessment tool from CMS. On the Home Health Care Web site, consumers can now review patients’ responses to the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey about care they received in Medicare-certified home health agencies. Data on overall care, their providers’ communications skills, and safety will be updated every 4 months.

    Medicare Part D beneficiaries with CV conditions falling between the cracks, or “donut hole” of financial coverage between 2006 and 2007 generally stopped taking their medications, instead of buying cheaper, generic alternatives, as opposed to those with consistent drug coverage, says a new study from Harvard University, Brigham and Women’s Hospital and CVS Caremark. Researchers stated that CV medications account for the largest proportion of spending and volume in the Part D program. The effects of this discontinuation are twofold: the short-term effects of stoppage didn’t result in any negative impacts; but the long-term effects were unclear.

    And finally, are you participating in an ACO? Or are you interested in learning about them? Either way, we invite you to participate in our second annual survey on ACOs. All respondents will be e-mailed an executive summary of results once the survey closes on May 16. A sneak peak at the data so far: health plans are helming a majority of ACOs; case managers are key players outside of providers. Even if you're not yet in an ACO, take the survey so you don't miss out on this eagerly anticipated research on this emerging model of care.

    All this and more in this week's issue of Healthcare Business Weekly Update.

    Q&A: Non-Compliance Drives Need for Telephonic Case Management

    April 23rd, 2012 by Jessica Fornarotto

    Though it emerges in different ways, non-compliance with care plans drives telephonic case management protocols for three distinct populations at Carolina Behavioral Health Alliance (CBHA), explains Jay Hale, its director of quality improvement and clinical operations.

    Prior to his presentation on Telephonic Case Management: Protocols for Behavioral Healthcare Patients, Hale defines the distinct groups of behavioral health patients, indicators of non-compliance for each, barriers faced by telephonic case managers, the involvement of PCPs and red flags signaling the need of an in-person visit.

    HIN: What is the number one reason behind high levels of inpatient or ER use by the behavioral health population?

    (Jay Hale): When we look at the behavioral health population, we’re looking at three different groups of individuals, but with one reason driving all of their care. The three groups are adult mental health, adults with substance abuse issues and children/adolescents, which is generally mental health but can be substance abuse as well. The number one condition that we see is non-compliance with treatment. This comes out in various ways with our mental health population. It comes out as having suicidal thoughts or homicidal thoughts, or other impulsive or dangerous actions that would cause someone to be referred to the ER.

    With our substance abuse population, we often see people who stop going to meetings, and/or who stop working with their sponsor and return to the behaviors that they were doing when they were drinking or using, which leads them back to drinking or using. Many of the relapse behaviors lead to using.

    Our child/adolescent population is usually a little more complex. Because they don’t have the same control over their environment that adults do, many times they will act out more in either school or home, and that acting out escalates to a point where they’re referred to an ER.

    Ultimately, it all comes back to failing to follow through with treatment for various reasons. Many times we begin to get some treatment early on and we get past the crisis, but it’s hard for people to accept that they have a chronic ongoing illness that needs ongoing treatment. Once they start to feel better, they stop or cut back on treatment, but then things begin to deteriorate for them and they don’t catch it until it’s at a crisis point where they’re back in the ER.

    HIN: What barriers may a telephonic case manager encounter when contacting someone with a mental health issue? What advice do you give the case managers on establishing rapport during these calls?

    (Jay Hale): One big barrier that we see is making sure that we have the member’s correct phone numbers. We want to make sure that we have updated information so that we’re calling the correct people. Another barrier is having the member on the other end trust us enough to accept our help, or accept our support, in their care.

    I advise our case managers to work with other people who are working with the member early on. We want to work with the hospital earlier before the person is discharged to get correct contact information and to let the member know that we’re going to be contacting them. We want to be part of that discharge plan and operation, and we want our case management program to be part of that plan as well — a plan that shows that the patient is going to the psychiatrist, or a therapist, and that they’re going to be followed up by us telephonically.

    When one of our case managers calls a member to invite them to be part of our program, we want to talk to the member about how the program helps them. We want to emphasize how this is helping them in their recovery for either a mental illness or for a substance abuse episode. With substance abuse individuals, we want to make sure that we are using the language that they are comfortable with in early recovery — language where we’re making sure we’re supporting their recovery program, they’re working their steps, they’re following through with their meetings, etc. We are letting them know that we understand their situation and that we’re supportive of them in their recovery. With mental health individuals, we want to make sure that they feel comfortable with us, that we are understanding their situation, and that we are not here to do counseling. Rather, we are here to support them in their recovery and to help them see the improvements that they’re seeing as they follow through with treatment.

    With our child/adolescent population, we’re usually working with the parents. Many parents are appreciative of the support that we can give them as they try to help their child or adolescent do better in school, do better at home and have a more successful life early on. We’re about letting the parent know that we’re not here to blame anyone for any situation that the child is in, but rather, we’re there to support them in having a healthier family and a healthier child.

    HIN: How involved is the individual’s primary care provider or any other providers in this process?

    (Jay Hale): The member’s providers are a very important part of our program. We want to make sure that the member is going to their sessions, is seeing their psychiatrist or therapist, is going to meetings, etc. We reach out early to those behavioral health providers to let them know the member is involved in the program, that we are not there to be between their relationship — we’re an adjunct to support that ongoing relationship — and to let them know we solicit their support in this service so that the member understands that we’re all working toward one goal. And that one goal is improvement of the member’s care and helping them be and live successfully outside of a hospital environment. One of the things we’re looking at in care management, or case management, is making sure that they’re attending sessions. Behavioral health providers often like to hear that the insurance company is encouraging people to go to sessions rather than limiting sessions. We usually get a lot of support from our providers for what we’re doing.

    HIN: You defined three very different groups. What are some indications or red flags that might arise during a call with a behavioral health client that could mean an in-person visit with a provider is warranted?

    (Jay Hale): One of the things we’re looking for is changes in symptoms. Those changes in symptoms, or changes in habits, could be asking the individual at each call about their depression; any type of mania that they may be experiencing, if there’s a history of such. We’re asking about any other psychiatric symptoms that they’re having and asking the member to rate them. Then, we look at our information to see how much of a change that is from the last time we spoke.

    If we start to hear about any kind of deterioration, we explore those issues further to see how serious it is — if it’s something that is temporary or something that is more ongoing. We’re also going to be looking for other factors, such as medication compliance. Is the person still following through with their medication? Did they have any difficulty with it? If they have, have they let their provider know they’re having difficulty with those medications? If we start to hear any kind of decompensation when we’re concerned about someone’s safety, or we’re concerned that someone is starting to slide back and return to the more unhealthy behaviors that they had in the beginning, we will make a phone call to that provider to see if we can get an appointment set up for that member to be seen quickly. This way, they can be assessed and changes in treatment can be arranged. Or it could be getting the member back into treatment again if they’ve fallen back or stopped going.

    With our substance abuse individuals, often we’re looking for frequency of going to AA meetings, frequency of contact with their sponsor or any kind of irritability, especially over going to meetings. Many times individuals will start to talk about how the meetings are not helping them. We want to help them problem-solve around other things that could help them more and encourage them to start going back to those meetings or start working with that sponsor. If that’s not working, we may help them get in contact with an outpatient therapist who specializes in substance abuse issues to help see if there are other mental health concerns that are driving some of these relapse behaviors.

    POWER Tool, Digital Dashboard Enhance Evidence-Based Case Management

    April 20th, 2012 by Cheryl Miller

    Conflicting care guidelines, misplaced mail and network drive limitations are a thing of the past for Arkansas Blue Cross Blue Shield case managers, thanks to a pair of productivity tools the Blues plan recently instituted.

    Dynasite, an Intranet repository of case management resources, and POWER, a rules-based electronic workflow management system that also serves as a document storehouse, keep case managers current and also streamline processes and documentation required for licensing, accreditations and certifications, explained Karen Black, RN, HIPAAP, improvement coordinator for Arkansas BCBS, during an April 11, 2012 webinar.

    Dynasite, a "digital dashboard of education," allows case managers to access quality improvement material, patient surveys, policies, time cards and more from their home page, explained Ms. Black during "Leveraging Case Management Tools and Technology to Improve Outcomes." Dynasite is a "growing dynamic document" to which resources are added regularly, said Ms. Black, once they are vetted by a quality committee.

    Dynasite fosters consistency and evidence-based care by case managers. For example, a care transitions form that resides on Dynasite follows the Blues plan member throughout the system of care.

    POWER is a "paperless operational workflow electronic routing" system that boosts productivity and oversight of case managers, helping Ms. Black to manage licensure issues for 110 nurses and reducing paper handling and copying. By virtue of being paperless, POWER reduces the risk of exposure of protected health information (PHI), speeds transfer of workloads between case managers and simplifies documentation required in the event of a URAC audit.

    It took four months from design to development of POWER, which was created by Pinnacle Business Solutions. The system was originally conceived to reduce mail distribution errors, but is now increasing case management productivity on many fronts. The potential for POWER is "almost limitless;" the system has been deployed in many other areas of the company that have a desire to go paperless.

    Both tools enhance telephonic case management and facilitate communication between case managers, Ms. Black added. Member education tools are the resources most frequently accessed by Arkansas BCBS case managers.

    To Curb Hospital Readmissions, Home Visits Double for Recently Discharged Patients

    April 16th, 2012 by Patricia Donovan

    Just months away from CMS penalties for what it deems 'excessive' hospital readmission rates, 75 percent of healthcare companies have launched programs to reduce avoidable hospital readmissions.

    The Healthcare Intelligence Network annual survey on Reducing Readmissions documented the highest rates of programs targeted to hospital readmission rates in the survey's three-year history.

    Across the board, focus has intensified from last year’s levels on patients with conditions CMS has identified as likely to trigger readmissions — cardiovascular disease, pneumonia, and stroke, as well as on the frail elderly and the commercial population.

    Effective management of a patient's transitions of care, such as from hospital to home or from hospital to nursing home, remains the most effective strategy for reducing readmissions, say 59 percent of respondents.

    Also, key interventions at the hospital discharge are performed more frequently: for example, home visits have more than doubled in the last year, and telephonic confirmation of follow-up appointments for recently discharged patients is up 15 percent.

    Case managers and registered nurses share equal responsibility for reducing readmissions, say a quarter of respondents, a trend representing a rise in responsibility from 2011 for the RNs.

    A total of 119 healthcare companies responded to the survey, administered in February 2012. Download an executive summary of the 2012 survey results.

    Meet Healthcare Case Manager Miriam Weiss: Learns Nurturing, Strength from Holocaust Survivor Parents

    April 12th, 2012 by Cheryl Miller

    This month we provide an inside look at a healthcare case manager, the choices she made on the road to success, and the challenges ahead.

    Miriam Weiss, MSN, RN, CCM, Care Manager at Amerigroup Corporation, Care Manager Consultant, Per Diem, at CareManagers Inc.

    HIN: What was your first job out of college and how did you get into case management?

    Miriam Weiss: My first job out of college was at my local hospital. I was hired as a graduate nurse on a medical-surgical floor. Non-computerized nursing boards were not until mid-July, so I was able to practice under the supervision of a licensed RN pending notification that I passed the nursing boards and was officially, an RN. It was a great opportunity to practice what I learned, both theoretically and clinically.

    I sort of fell into case management. My port of entry was via home healthcare. In 1977, before home care agencies were compensated for social workers, nurses were responsible for collaborating, facilitating, advocating, and planning for services and interventions to meet patient needs.

    Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

    My defining moment came within the last decade. I knew I was in the right place at the right time based on the feedback I received from my clients, and the feedback and performance appraisals I received from my colleagues saying that I was doing what I was meant to do. Also, I realized that I was able to balance my personal life with my professional life and not have to compromise. When I can say my life is balanced and fulfilled, that is my defining moment.

    In brief, describe your organization.

    Amerigroup Corporation is a managed care organization that provides access to healthcare for low income individuals and families, persons with disabilities, as well as Medicare benefits for those enrolled in publicly funded health care programs.

    What are two or three important concepts or rules that you follow in case management?

  • Encourage self-determination, and
  • Provide tools to enhance self-care abilities that promote and improve healthier behaviors.
  • What is the single most successful thing that your organization is doing now?

    It is moving forward to acquire NCQA recognition in New Jersey.

    Do you see a trend or path that you have to lock onto for 2012?

    I see healthcare becoming more challenging given the current socio economic turmoil in the nation and in the existing political arena. I also see the benefits of various programs under consideration, particularly, the medical home model concept.

    What is the most satisfying thing about being a case manager?

    I find the most satisfying and gratifying results of my position are positive health behaviors adopted by the clientele.

    Where did you grow up?

    I was raised by Holocaust survivors, on a chicken farm in rural southern New Jersey. My mother lost her mother at age 14. She was not lacking for nurturing role models or nurturing skills, which I witnessed during my formative years, as she tended to my maternal grandfather as he fought cancer. My paternal Aunt Fanny was an LPN and I was privileged to be on the receiving end of their tender, caring natures. The two of them most influenced my decision to become a nurse. When chicken farming was no longer a profitable business, my parents took up massage therapy training and started a new enterprise. I am certain observing them in massage therapy also contributed to my career choice.

    What college did you attend?

    I received my BSN from Fairleigh Dickinson University in New Jersey. I received my master’s degree in nursing administration in 2001, at Wagner College, NY, having begun this program at age 40. I was balancing full-time employment in home care, pursuing my master's degree, and balancing time to be with my family. If ever there existed a challenge in my life, this was truly the time.

    Is there a moment from that time that stands out?

    There are so many moments during my four years on campus that stand out: the lectures on anatomy and physiology, the dissection of a cat, the clinical rotations to various hospitals, the dormitory lifestyle, and the beautiful campus.

    Are you married? Do you have children?

    I have been married for 36+ years; I have two married daughters and one granddaughter. My husband and I are blessed that both mothers, ages 89 and 86, are relatively healthy. Their needs add to the challenge of balancing career and home. I am part of a sandwich generation and the demands that position creates.

    What is your favorite hobby and how did it develop in your life?

    I have always enjoyed sewing, although I do much less of that now than when I was growing up. Now my favorite activity is some sort of exercise, be it walking and exploring new geography or going to the gym to really sweat it out. I also enjoy reading, mostly Danielle Steele, John Grisham, James Patterson, or Lisa Scottoline. Summers will find me at the beach when possible.

    Is there a book you recently read or movie you saw that you would recommend?

    I loved “The Artist.” I am very happy to say I saw it before it was recognized by the Academy of Motion Pictures.

    Any additional comments?

    I am pleased to report that I have been published a couple of times, and continue to be inspired to write from personal experiences: Surviving a Downsizing, Merger, Restructuring…and Any Other Euphemism, Home Healthcare Nurse, February 1999; and Medication Use Risk Management: Hospital Meets Home Care, Home Health Care Management and Practice, February 2000

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