Hospital Case Management
Who are they and what they do…
The Case Management team is a group of professionals that assist patients and families in navigating the complexities of the health care environment. An understanding of the whole person is necessary to develop a patient centered plan of care. The Case Management staff may ask about social support, financial and insurance information as well as other areas that are integral to ensure the safe and appropriate discharge of patients from the hospital setting. Sometimes this can be concerning to patients or families who are stressed because of illness or injury, so understanding there is a team assisting with any needs and why they are asking probing questions is often reassuring. Members of the Case Management team include the Nurse Case Manager who oversees the clinical, financial and operational outcomes of every patient’s stay. They assess, implement and monitor the care coordination including discharge planning. They communicate the plan to the patients and families as well as the patient’s insurance company. Social workers provide discharge planning and/or psychosocial support including referrals to Community Resources, Crisis Intervention and Counseling.
The Case Management team may ask detailed questions regarding whether a Medicare patient has been hospitalized or has been in a rehabilitation setting recently. This is related to the Medicare “Benefit Period.” A Benefit Period begins the day the Medicare beneficiary is first admitted to a hospital and ends when they have been out of a hospital or a Skilled Nursing Facility for 60 consecutive days. This is important because the potential out-of-pocket costs are determined by the number of days utilized in the “Benefit Period.” There may be a copayment depending on the days used in the Benefit Period. For example, beginning on day 21 of a Skilled Nursing Facility stay, the Medicare member will have a copayment that he/she will be responsible for unless there is secondary or supplemental insurance to assist with the cost.
Case managers have knowledge of, and can provide education on, Lifetime Reserve Days for traditional Medicare beneficiaries as well. If a beneficiary has been in a facility for more than 150 days in a Benefit Period, they can opt to use their Lifetime Reserve Days. Each beneficiary receives 60 of these days which can only be used once in a lifetime. If these days are used Medicare will pay all of the covered costs except for a daily coinsurance amount however these days do not regenerate.
Medicare has very specific guidelines regarding hospital admission and this is often confusing for patients and families. Medicare states that Observation care is “specific, clinically appropriate services, including ongoing short-term treatment, assessment and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.” Hospitals must abide by this Medicare definition and this can cause confusion for patients and families when the patient requires Skilled Nursing facility level of care. For traditional Medicare beneficiaries a 3 night medically necessary Inpatient stay is required for the patient to discharge from the hospital to a Skilled Nursing facility and use their Medicare benefit. Observation nights do not count toward the 3 night qualifying stay. However, if a patient spent 3 nights in the hospital as an Inpatient and discharged home and within 30 days the family feels the patient needs to go to a Skilled Nursing facility, the Skilled Nursing benefit can still be utilized without readmission to a hospital. This does require coordination as there may be a need for a TB skin test depending on the state regulations; however Primary Care Providers or Home Health Care can assist with this requirement.
Managed Medicare plans, for example Humana or United Healthcare, waive the 3 night medically necessary Inpatient stay for admission to a Skilled Nursing Facility. Managed Medicare members can utilize their Skilled Nursing Facility benefit without an Inpatient admission to the hospital and can be admitted to a Skilled Nursing facility from home. It is very important when selecting a Managed Medicare plan that beneficiaries find out what Rehabilitation and Skilled Nursing facilities are in the network they are considering. For example, there may not be an in-network facility in the city where the member lives and this needs to be considered prior to final selection of a Managed Medicare plan.
Discharge planning and care coordination are the primary focus of the Case Management team in the hospital. Case Managers and Social Workers possess the knowledge and expertise to navigate the complexities of today’s healthcare system. Collaborating and developing a patient centered plan of care and creating a smooth transition provides everyone with peace of mind in a time that can be stressful and the Case Management team members are the experts in this area.
Tamara Pruett is a RN Certified Case Manager and is the Director of Case Management at East Cooper Medical Center, a 135 bed hospital in Mount Pleasant SC. Tamara has worked in Labor and Delivery, the Physician’s office setting, Home Health Care, Acute Rehabilitation and the Hospital. Prior to coming to East Cooper, Tamara was a Director of Case Management in Mesa Arizona as well as the System Educator for Case Management for a 27 hospital system in Arizona. Tamara has also authored educational modules for the American Case Management Association (ACMA). Tamara and her husband enjoy fishing and spending time with family and friends.