Care Transformation Center Blog

Is hospital care management stuck in the Stone Age?

In many ways, we’re still in the Stone Age of inpatient care management. All too often, hospitals focus their care management activities on a singular episode of care within the acute setting, and then call it a day.

But the hospital is often only one stop in a patient’s total journey, and a narrow focus—by facility or even just by department—means missing out on other significant touchpoints. So, how do you know if your hospital’s care management functions are set up to deliver comprehensive and coordinated services, and promote success under value-based contracts?

The essential 5 keys hospitals need to best prepare a patient for a post-acute discharge

Diagnose your inpatient care management

When my team of hospital management consultants is called on to assess the state of inpatient care management, we start by helping clients answer the following questions:

  • Clinical staffing: What does your staffing structure look like? What’s the ratio of care managers to patients? What responsibilities do care managers have? What is the mix of social workers? Is everyone working at top-of-license?

  • Finances: What is the rate of denials? Have there been high readmission penalties? Are high income DRGs weighed down by a high average length-of-stay?

  • Operations: How do care managers prepare for the day ahead? What is the relationship between care management nurses and physicians? Does staff know how to make appropriate handoffs, and when to escalate issues to senior leadership?

Once we have the full picture, issues like inappropriate admissions, avoidable days, or staffing siloes quickly emerge—along with major financial and clinical opportunities. And while some of the solutions are low-hanging fruit, they can make a world of difference. For example, on the operational side, we help clients implement interdisciplinary, daily meetings where physicians, nurses, ancillary staff, and leadership from care management and nursing come together to discuss each patient, and whether there are concerns with admissions, length of stay, or coordination of care.

Include post-acute partnerships in your care management function

Once a patient is discharged from the hospital, I tend to see many hospitals’ care management efforts fall short. Whether the patient needs to be transferred to a post-acute care facility, or receive ongoing care on an outpatient basis, there are often different standards of care and a varying skill mix between sites, making it difficult to ensure they receive the right level of care once they leave the hospital.

To bridge the gap between acute and post-acute care, hospital leadership should establish two kinds of care management partnerships: post-acute facility partnerships to standardize care for the entire patient journey; and community partnerships to ensure patients have access to preventive resources in the future—such as drug screenings or counseling.

For instance, one hospital we worked with partnered with local skilled nursing facilities to ensure consistent transitional care for heart failure patients, which in turn improved the overall quality of care and reduced readmissions. Once these types of partnerships are in place, care managers at participating facilities should work collaboratively to design standardized care procedures, consistent quality standards, and transfer protocols.

As hospitals put more of their business in value-based contracts, coordinated and comprehensive care management surrounding the acute setting will go a long way to promote broader population health management objectives.


5 ways to effectively manage patients after they've been discharged

In this downloadable resource, we delve into how to manage patients post-discharge to ensure recovery, avoid readmissions, and hardwire appropriate post-acute utilization.