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Limiting Hospital Readmissions: The Role of Case Management

By Jennifer S. Kiesewetter, Esq | Jun 20, 2018

Hospital readmissions are costly, and the high frequency of these readmissions has drawn scrutiny — not just from plan sponsors, but from hospitals, plan payers and the government. In fact, "health care reform has pinpointed hospital readmissions as a key area for improving care coordination and achieving potential savings," according to the Agency for Healthcare Research and Quality (AHRQ).

However, many readmissions — defined as admissions that take place within 30 days of a patient's initial discharge — can be avoided with improved care coordination. Below, we identify ways that case managers can decrease members' readmissions, thereby driving down the fund's costs.

The High Costs of Readmissions

The AHRQ study noted that in 2011, approximately 3.3 million adults were readmitted to hospitals across all payers — Medicare, Medicaid and private insurance — costing $41.3 billion. Medicare patients represented the largest share of readmissions and associated costs across the three payers studied. While private insurance had the lowest share of readmissions, it had the second highest associated costs.

For privately insured patients (18 to 64 years old), the three conditions with the highest number of readmissions were maintenance chemotherapy, mood disorders and surgical or medical care complications. When combined, these conditions led to approximately $785 million in hospital costs, the AHRQ study noted.

How Can Case Managers Decrease Readmissions?

Case managers can significantly reduce hospital readmissions — thus positively impacting a fund's bottom line — by doing the following:

  • Integrating Case Management With Medical Care: Case managers should no longer write up a discharge plan that's bound to the hospital visit, according to AHC Media. Today's discharge plan should extend beyond the hospital. Thus, case managers must work closely with primary care doctors, rehabilitation facilities and others participating in the member's health care to ensure that proper follow-up care occurs. Doing so will serve to reduce the likelihood of readmission.
  • Providing Access to Records Across the Continuum: To provide follow-up care across the continuum, case managers need to have access to the member's medical records, according to AHC Media. Oftentimes, when the patient goes to his or her primary care physician for a follow-up, the physician doesn't know which tests were completed in the hospital, increasing the likelihood that duplicate tests are run. In addition, little to no communication tends to occur between a patient's various different health care providers, each of whom have access to different pieces of the patient's record. In order to implement a comprehensive approach to member care, the case manager should act as the point person who ensures the necessary communication takes place between all providers.
  • Identifying Gaps in Care: As McKesson reports, "research indicates that more than 25 percent of all readmissions within 30 days of discharge are for conditions unrelated to the initial admission." By understanding a patient's full medical history, case managers can quickly identify any gaps in care that may lead to readmission.

Benefits to the Fund

Integrated case management promotes increased efficiencies. The time and costs savings can be a benefit to both plan and member. Potential benefits for the fund include:

  • Reducing members' readmission rate
  • Controlling costs
  • Happier members, thanks to a better quality of care
  • No time lag with claims, which can happen with third-party vendors

Ultimately, benefiting members also benefits the fund. Encouraging case managers to have a more active role shows that trustees care about members' health care experience. Doing so also provides a healthier bottom line for the fund by reducing duplicate services and the number of overall readmissions.

Jennifer Kiesewetter, founding and managing member of Kiesewetter Law Firm in Memphis, Tennessee, is a seasoned attorney in the field of employee benefits. Ms. Kiesewetter's practice includes regulatory compliance and governance with the Employee Retirement Income Security Act of 1974 (ERISA), the Internal Revenue Code and the Affordable Care Act (ACA), in addition to the other federal laws governing employee benefits and health care compliance regulatory law. She's also an Adjunct Professor of Employee Benefits at University of Memphis Cecil C. Humphreys School of Law. Additionally, Ms. Kiesewetter is a frequent writer and speaker on the topic of employee benefits and health care compliance regulatory law, locally, regionally and nationally.

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