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Exploring the Effect of At-Risk Case Management Compensation on Hospital Pay-for-Performance Outcomes: Tools for Change

Granata, Randy L. RN-BC, DNP, CMAC; Hamilton, Karen PhD, RN

doi: 10.1097/NCM.0000000000000067
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Purpose/Objectives: Acute care nurse case managers are charged with compliance oversight, managing throughput, and ensuring safe care transitions. Leveraging the roles of nurse case managers and social workers during care transitions translates into improved fiscal performance under the Affordable Care Act. This article aims to equip leaders in the field of case management with tools to facilitate the alignment of case management systems with hospital pay-for-performance measures. A quality improvement project was implemented at a hospital in south Alabama to examine the question: for acute care case managers, what is the effect of key performance indictors using an at-risk compensation model in comparison to past nonincentive models on hospital readmissions, lengths of stay, and patient satisfaction surrounding the discharge process.

Primary Practice Setting(s): Inpatient acute care hospital.

Findings/Conclusions: The implementation of an at-risk compensation model using key performance indicators, Lean Six Sigma methodology, and Creative Health Care Management's Relationship-Based Care framework demonstrated reduced length of stay, hospital readmissions, and improved patient experiences.

Implications for Case Management: Regulatory changes and new models of reimbursement in the acute care environment have created the perfect storm for case management leaders. Hospital fiscal performance is dependent on effective case management processes and the ability to optimize scarce resources. The quality improvement project aimed to further align case management systems and structures with hospital pay-for-performance measures. Tools for change were presented to assist leaders with the change acceleration process.

Randy L. Granata, RN-BC, DNP, CMAC, is Director, Department of Care Coordination, Providence Hospital, Mobile, AL. Randy Granata has more than 27 years of nursing experience across the care continuum. She has served in leadership positions in acute care environments and postacute settings including home health administration. Over the past 15 years, areas of focus include care coordination and chronic disease selfmanagement. Dr. Granata earned her Bachelor of Science in Nursing from the University of Illinois at Chicago and Master of Science in Community Health Nursing from Northern Illinois University. She recently completed her Doctor of Nursing Practice from the University of South Alabama with specialization in Public Health Nursing Administration. She is a member of the American Case Management Association and holds certifications in home health care from the American Nurses Credentialing Center and is also certified as a Case Management Administrator. Dr. Granata presently serves as Director of Care Coordination at Providence Hospital, a member of Ascension Health in Mobile, AL. Additional community roles include serving as Vice-President of Healthy Gulf Coast Care Transitions, a formal coalition consisting of four separate hospitals and over 50 post-acute providers which work collaboratively in the community to create better outcomes for patients and families through improved care transitions.

Karen Hamilton, PhD, RN, Associate Professor, Department of Community-Mental Health, University of South Alabama School of Nursing, Fairhope, AL.

Address correspondence to Randy L. Granata, RN-BC, DNP, CMAC, Department of Case Management, 6801 Airport Boulevard, Mobile, AL 36608 (rgranata@providencehospital.org).

This quality improvement project was not funded by any entity but was supported by Providence Hospital, a member of Ascension Health. The institutional review boards for Providence Hospital and the University of South Alabama considered the project to be exempt from the full review process.

The authors report no conflicts of interest.

© 2015 Wolters Kluwer Health | Lippincott Williams & Wilkins.