3 Collaborative Strategies to Improve Complex Case Management
Taking a collaborative approach in managing highly acute and complex cases improves patient outcomes and revenue performance.
It’s often challenging for health systems to manage complex care cases as effective management requires triaging across quality of care, patient experience, and cost effectiveness. Patients with multiple chronic conditions, comorbidities, and challenges related to social determinants of health (SDOH) experience frequent readmissions and longer lengths of stay (LOS). This can be detrimental to patient health outcomes and hospital finances.
Take a deeper look at the challenges with complex case management and three strategies that health systems can apply to improve outcomes.
Challenges with Treating Highly Acute and Complex Patients
Social Determinants of Health
Many complex cases are marked by social factors that impact health outcomes. Patients who experience unstable housing, food insecurity, limited income, or poor access to follow-up care are more difficult to discharge safely.
The implication for hospitals? Extended LOS, frequent readmissions — which often are not approved by payors — and stop-and-go care cycles that are harder to resolve.
Patient Experience
Frequent readmissions or extended stays are frustrating and can be stressful to patients. Poorly-managed care transitions can negatively impact their overall experience with the hospital, to the detriment of HCAHPS scores, hospital ratings, and reimbursement levels. Keeping patients satisfied (and out of the hospital) requires a coordinated approach to care transitions.
Fragmented Operations
Clinical teams and revenue cycle departments don’t often get opportunities to communicate. When new processes are rolled out on the clinical side, it isn’t always clear why those changes are important to patient care. Without a clear line of communication, it’s harder to enhance processes across the board, as a team — especially in complex case management.
Financial Impacts of Readmissions
Frequent readmissions often lead to denials and penalties from Medicare and other payors. This becomes costly to a hospital’s bottom line, resulting in downstream financial losses that can impact resources available for patient care across the hospital and care continuum.
The Importance of Collaboration in Complex Case Management
The challenges above make for a vicious cycle. Complex cases marked by significant SDOHs lead to frequent readmissions, which negatively impact hospital revenue. These financial burdens have implications for care quality (leading to more readmissions in turn) and patient experience (which ultimately affects revenue performance).
How can a health system end the cycle? Collaborative, thoughtfully-coordinated care management for highly acute and complex patients. When complex cases are effectively managed, hospitals see fewer readmissions, better use of resources, and fewer payor denials.
3 Collaborative Approaches to Managing Complex Cases
1. Align Internal Stakeholders
Start by getting key stakeholders on the same page. Schedule regular meetings between physicians, care coordinators, and utilization managers to discuss complex cases in real time. These conversations can help your teams:
Get complex care patients appropriately resourced
Identify opportunities in the discharge process, including any post acute provider barriers and challenges
Identify payor trends to escalate to managed care/payor contracting leadership
2. Communicate Proactively With Payors
Hospitals often plan for regular meetings with payors to review the needs of complex patients. Quarterly calls with payors are a step in the right direction, but this may not be frequent enough to get ahead of nagging challenges that impact hospital revenue.
Consider implementing standing meetings between utilization managers, care coordinators, and payors on a more frequent basis. This enables your hospital to address significant needs as they emerge, in order to:
Get ahead of denials
Handle resourcing proactively
Share accountability and responsibility with payors
3. Engage Physician Advisors for Appeals
Even with the best planning and collaborative processes in place, denials happen — especially in the case of readmissions. In order to get them overturned and recoup payment, engage experienced physician advisors who can help you appeal the denial.
It’s important not to give up after receiving a denial. Take the opportunity for an internal physician advisor or an outsourced vendor to initiate a peer-to-peer review. An effective physician advisor will review the case in detail with payors, explaining the patient’s background, reasons for dissent with the decision, and the unpreventable factors that resulted in readmission. This can help your hospital overturn denials, keep revenue in-house, and ensure patients get the care they need.
Streamline Complex Case Management With Trusted Partners
Managing complex cases requires proactive collaboration between both internal stakeholders and payors. By applying collaborative strategies, hospitals can prevent unnecessary readmissions, reduce financial strain, and improve health outcomes for highly acute and complex care patients.
At Eclipse Insights, we help hospitals implement strategies to optimize financial performance. Reach out to start the conversation about streamlining complex case management within your hospital.