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Case Management Accountability for Safe, Smooth, and Sustained Transitions: A Plea for Building “Wrap-around” Case Management Services Now

Zander, Karen RN, MS, CMAC, FAAN

doi: 10.1097/NCM.0b013e3181e26a80
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Purpose: The purpose is to encourage hospital administrations to address readmissions immediately and to restructure and significantly enhance case management services once and for all so that they can provide a “wraparound” service for the full clinical course from admission to transition for all patients and families. If 10 basic interventions cannot be provided because of staffing limitations or processes, case management will continue to operate in a crisis mode and hospitals will suffer potentially large financial, quality, and satisfaction losses. If further customization cannot be provided to patients and their families, hospitals will be at risk to fail both their margin and their mission. Although other professionals and support staff will have distinct responsibilities, case management must be built, resourced, and restructured to be the authorized and accountable central control operation between level-of -care transitions.

Primary Practice Setting: Acute care hospitals.

Implications for Case Management: The national length of stay (LOS) has lowered from 7.8 days in 1970 to 5.2 days (males) and 4.5 days (females) in 2006 (DeFrances, C., Lucas, C., Buie, V., & Golosinskiy, A., 2008), whereas the national readmission rate for adult medical-surgical patients, depending on the diagnosis and the payer, has risen from a range of 5%–29% after 30 days (The Center for Case Management, 2009) to an average of 19% (Jencks, S., Williams, M., & Coleman, E., 2009). Of the key results for return on investment claimed by case management, the largest combined measure of quality, financial, and satisfaction outcomes lies in the delivery of safe, smooth, and sustained discharges/transitions. In other words, readmission rates should be the conscience of the hospital, especially of case management services. 2010 is the year for case management services and departments to adamantly request the authority and take the accountability that will be required to prevent readmissions while maintaining or continuing to decrease LOS, thus increasing flow and capacity. To achieve full accountability for 100% of patients' transitions from admission to transition, case management must build a wraparound service that covers 10 basic interventions and a handful of best practices to customize each transition. Two principles pertain: (1) If you have not met the patient or family until the discharge day, you don't know them and will make mistakes, and (2) there is no such thing as a simple discharge! If hospitals do not undertake the full support of case management as the accountable agent for preventing readmissions as their biggest challenge (potentially larger than Retrospective Audit Contractors' financial take-backs) and provide case management with a full contingent of strategically positioned full time equivalents (FTEs), hospitals and their patients and families will suffer from a predictable imbalance in LOS, readmissions, and the greater community's loss of confidence.

Karen Zander, RN, MS, CMAC, FAAN, is principal and co-owner of The Center for Case Management, providing care and case management leadership, consultation, clinical tools, training, the New Definition Web-based newsletter, and numerous publications worldwide for 25 years.

Address correspondence to Karen Zander, RN, MS, CMAC, FAAN, The Center for Case Management, 386 Washington St., Wellesley, MA 02481 (kzander@cfcm.com).

The author has no conflict of interest.

Two principles pertain: (1) If you have not met the patient or family until the discharge day, you do not know them and will make mistakes, and (2) there is no such thing as a simple discharge!

© 2010 Lippincott Williams & Wilkins, Inc.