Case management is a collaborative process that includes the assessment, planning and coordination of options and services to meet a patient’s medical care needs. Effective case management utilizes available resources to achieve high-quality and cost-effective outcomes.
Transition planning is one function of case management. In the hospital setting, case managers assist patients and families in developing a discharge plan, including coordination of community based medical services and, when necessary, admission to a post-acute care facility, such as an acute rehabilitation unit or hospital, or skilled-nursing facility.
Case management is a collaborative process that includes the
assessment, planning and coordination of options and services to
meet a patient’s medical care needs. Effective case management
utilizes available resources to achieve high-quality and
Transition planning is one function of case
management. In the hospital setting, case managers assist
patients and families in developing a discharge plan, including
coordination of community based medical services and, when
necessary, admission to a post-acute care facility, such as an
acute rehabilitation unit or hospital, or skilled-nursing
Another function of hospital case managers is utilization
review (UR). UR is a cost control mechanism, whereby the
appropriateness, necessity and quality of health care services
are monitored by payers and providers. Hospital case managers
assist in this process by providing clinical information to
payers, monitoring length of stay, seeking necessary care
authorizations, and appealing medical denials.
In health care settings, case managers are most often nurses or
social workers. CHA supports the case management staff of our
member facilities through communications and advocacy at both
state and federal levels.
The Department of Health Care Services (DHCS) last week received
federal approval of a three-year extension of its Cal MediConnect
(CMC) program, which provides coordinated services to patients
who are dually eligible for Medicare and Medicaid.
The Centers for Medicare & Medicaid Services (CMS) has issued the
proposed rule for the inpatient rehabilitation facility
prospective payment system (IRFPPS) for federal fiscal year
(FFY) 2020. If finalized, the provisions would be effective Oct.
The California Department of Public Health (CDPH) Stroke
Registry/California Coverdell Program requests that hospitals
participate in its annual stroke survey. Responses to the survey
will be used to assess hospitals’ capacity to provide stroke
care, describe the quality improvement intervention work underway
in hospital settings, and identify acute stroke care service
CHA has submitted
comments to the Department of Veterans Affairs (VA) on its
proposed rule implementing the Veterans Community Care
Program, which will replace the Veterans Choice Program as
required by the MISSON Act of 2018.
On July 1, 2019, SB 1152 requires hospitals to have a written plan for coordinating services and referrals for homeless patients. Successful implementation will hinge upon working with your regional health care and social service agencies to ensure appropriate homeless patient discharge. Further, the law requires that hospitals maintain a log of homeless patients discharged and the destinations to which they were released after discharge.
informational series from the California Health Care
Foundation explains various facets of the Medi-Cal program,
including a program overview, challenges of program
eligibility and enrollment, the process and challenges of
payments to Medi-Cal managed care plans, the 2019 edition of
Medi-Cal facts and figures, the intersection of Medi-Cal and
behavioral health, and the Medi-Cal budget process.
The Department of Health Care Services (DHCS) recently requested
input on how the Cal MediConnect program can provide a better
member experience or otherwise improve care and care
coordination. Today, CHA submitted
comments that outline the challenges hospital case managers
continue to experience in the discharge planning process.
Later this year, the Department of Health Care Services (DHCS)
will modify access to the Hospital Presumptive Eligibility (HPE)
Application Portal. Providers who have not yet updated their HPE
user information should do so to ensure they do not lose access
to the portal.
The Centers for Medicare & Medicaid Services (CMS) has announced
Part D Payment Modernization model, available through the
Center for Medicare and Medicaid Innovation, for Part D and
Medicare Advantage (MA) drug plans beginning in January 2020.
CHA has submitted
comments to the Centers for Medicare & Medicaid Services
(CMS) on its release of preliminary findings from the national
beta test of standardized patient assessment data elements
CHA submitted the attached comment letter responding to the
Centers for Medicare & Medicaid Services’ (CMS)
proposed rule that would change managed care regulations for
Medicaid and the Children’s Health Insurance Program (CHIP).
While most of the rule’s proposals are technical adjustments or
changes that have little impact on the Medi-Cal managed care
program, some could impact the managed care portion of the
Hospital Fee Program.
Facilities Letter 18-57, the California Department of Public
Health announces a new web-based data collection tool intended to
assist providers that participate in the Palliative Care Pilot
Program with annual reporting. Program participants must submit
certain information using this tool by Jan. 1 of each program
year. 2018 reports were due Jan. 1, 2019, but the
online reporting portal will remain open through March 1.
The California Department of Public Health has issued All Facilities
Letter 19-01 reminding hospitals of the new law requiring
that they try to coordinate homeless patients’ discharge to
appropriate area shelters or other community-based
services. To help hospitals comply with the law, CHA
has developed a guidebook titled Discharge
Planning for Homeless Patients.
The Centers for Medicare & Medicaid Services (CMS) has issued a
fact sheet announcing that it expects a temporary
gap for the Medicare Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies Competitive Bidding Program to last until
Dec. 31, 2020.
The Centers for Medicare & Medicaid Services (CMS) last week
finalized a rule that suspends the Durable Medical Equipment,
Prosthetics, Orthotics, and
Supplies (DMEPOS) Competitive Bidding
Program beginning Jan. 1. CMS expects that the program
will be suspended until at least Dec. 31, 2020.
The Centers for Medicare & Medicaid Services (CMS) has extended
until Nov. 9, 2019, its timeline for revising discharge planning
requirements for hospitals, critical access hospitals and home
On Nov. 3, 2015, CMS proposed updates to discharge planning
requirements that included provisions required by the Improving
Medicare Post-Acute Care Transitions (IMPACT) Act of 2014. At
that time, CHA
submitted a comment letter on members’ behalf. Based on the
numerous comments and information it received, CMS has determined
that significant policy issues must be resolved and it needs
additional time to coordinate with other government agencies.
More information is available in the attached notice.
CHA has developed the attached issue brief to summarize member
concerns about lack of timely access to durable medical equipment
(DME) for Medicare beneficiaries upon hospital discharge. This
challenge has become increasingly acute since the Centers for
Medicare & Medicaid Services implemented its Competitive Bidding
Program. The issue brief includes results from a survey of more
than 400 hospital-based case managers, as well as case examples
and policy recommendations, and will be used to support CHA’s
ongoing advocacy on this issue.
As a reminder, the Centers for Medicare & Medicaid Services (CMS)
will host a special open door forum on post-acute care quality
reporting programs July 25 at 11 a.m. (PT). During the forum, CMS
staff will provide information and solicit feedback about the
standardized patient assessment data elements (SPADE), including
an update on the progress of national field test data collection,
feedback from providers participating in the beta test and
upcoming stakeholder engagement activities. Development and
implementation of the SPADE comply with the requirements of the
Improving Medicare Post-Acute Care Transformation Act of 2014
Note that the dial-in previously provided by CMS has changed to
(800) 857-1738, passcode 7785347.
The Centers for Medicare & Medicaid Services (CMS) has issued the
attached interim final rule, which would increase payments for
certain durable medical equipment and enteral nutrition items in
rural areas that are not subject to the Durable Medical
Equipment, Prosthetics, Orthotics, and Supplies Competitive
CMS previously attempted to transition payments from traditional
fee schedule amounts to competitive bid rates. In 2016 and 2017,
the agency used information from the Competitive Bidding Program
to adjust Medicare payments for certain durable medical equipment
and enteral nutrition items in areas that were not part of the
program. In 2016, blended rates — 50 percent of the
amount based on the competitive bid rates and 50 percent of
the traditional fee schedule amounts — were implemented for a
transitional year. Beginning Jan. 1, 2017, the fully adjusted fee
schedule rates took effect. However, CMS notes that stakeholders
have raised concerns about the significant financial challenges
posed by the current adjusted fee schedule rates and that the
number of suppliers in certain areas continues to decline.
To protect access to needed durable medical equipment in rural
and non-contiguous non-bid areas, CMS’ interim final rule resumes
the blended rates from June 1, 2018, to December 31, 2018.
Comments on the interim final rule are due July 9.