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Membership Continuing Education
Embedded Case Management Model Leads to Measurable Improved Outcomes & Reducing Heart Failure Readmissions with a Complex Care Team

Publication Date: 5/4/2023


Embedded Case Management Model Leads to Measurable Improved Outcomes

Length: 58 minutes 31 seconds

Content Level: .5 Intermediate CE

Abstract
With increasing focus on value-based care, care coordination has become a priority in U.S. health care organizations in order to increase patient safety and to maximize efficiency. To address this issue, we launched an embedded case manager (ECM) model in five hospitals in a large integrated health care system. With redefined roles and physician-aligned assignments, ECMs worked proactively with the multidisciplinary care team to address patients’ discharge needs and ensure smoother transition to post-acute care. The ECM model received broad support from frontline staff and was associated with improvements in patient experience, efficiency and outcomes. After weighing the favorable evidence for efficiency and outcome metrics with health care team support, administrators expanded the ECM model to more sites, spanning other care settings such as accountable care organizations (ACOs) and home health.

Learning Objectives
1. Identify the added value of a physician-aligned, embedded case manager model compared to a traditional model.
2. Illustrate the framework of integrating multiple measures to evaluate care coordination initiatives.
3. Demonstrate the value of rigorous program evaluation to understand stakeholder engagement program implementation and effects on outcomes.
4. Recognize the potential for application of the ECM care delivery model to your organization.

Speaker: Jan Ernest, MSN, RN, NEA-BC | Executive Director, Integrated Care Systems | BJC HealthCare

Jan Ernest received a master’s and bachelor’s degree in nursing from the University of Evansville and is board certified by ANCC as a Nurse Executive Advanced. Ms. Ernest is System Executive Director for Integrated Care Services at BJC HealthCare in St. Louis, Missouri. Jan has over 40 years of health care experience with extensive experience leading change, developing business strategy and operational plans and engaging the entire health care team to meet the changing demands of clinically integrated, value-based care.



Reducing Heart Failure Readmissions with a Complex Care Team

Content Level: .5 Intermediate CE

Abstract
Despite advancement in medical therapy and rising CMS penalties, hospital readmission rates continue to be high in patients with Congestive Heart Failure (CHF). In an effort to reduce readmission rates and improve health outcomes of this population, this health system utilized a multidisciplinary approach, identifying team members within the inpatient and outpatient setting to follow CHF patients throughout the transitions of care. The designated team members included the following staff in the Heart Failure Program: a nurse manager, nurse practitioners, cardiologists and an inpatient care manager. Outpatient team members included a designated transitions of care (TOC) Care Manager and a Clinical Social Worker. They also partnered with a free community clinic, which provided follow-up care for unfunded patients. In this session, presenters will share program best practices, tools and lessons learned. Outcomes included a positive trend in readmission rates, development of a daily CHF multidisciplinary huddle between inpatient and outpatient team members and justification for a designated CM/SW team to work with the CHF population.

Learning Objectives
1. Assess current need for a pilot dedicated to reducing readmissions in a single disease population.
2. Develop an assessment tool for patients with heart failure at risk of readmission.
3. Examine a transitions of care assessment tool for patients with heart failure at risk of readmission.
4. Apply concepts to create a multidisciplinary team to follow the patient from inpatient to outpatient setting.

Speaker: Rebecca Castro, LCSW, ACM-SW | Manager, Social Work, Care Management | UTMB Health

Rebecca L. Castro is a Clinical Social Worker and Accredited Case Manager with over 25 years of health care experience and more than 15 years in leadership. She currently practices as a Manager of Social Work in the Department of Care Management at UTMB Health in Galveston, Texas. Ms. Castro has held positions as a team member and manager in many areas of care management, including the Emergency Department, Inpatient, Community and Outpatient Clinics and credits her current team with having the grace and patience to help her continue to develop as a leader. Ms. Castro is proud of her time spent as a member of a variety of community boards, including the Teen Health Center, Community Assistance Providers of Galveston County and The Salvation Army of Galveston County, believing that the best way to serve your community is to be an active part of it.

Speaker: Toni Shultis, RN, MSN, CCM | Manager, Ambulatory Care Management | UTMB Health

Toni Shultis is a Registered Nurse and Certified Care Manager, currently leading the Community Health Program and Transitions of Care at UTMB Health in Galveston, Texas. The Community Health Program is a novel approach that utilizes Certified Community Health Workers alongside RNs to facilitate learning and change in the unsponsored, chronically ill population. Ms. Shultis has held a variety of leadership roles in the public and health plan settings and enjoys facilitating transitions between inpatient and outpatient settings.

Please Note: Session was originally presented live at the 2022 ACMA National Conference on May 1-4 in Dallas, TX.

Keywords: Care Coordination, Readmissions

Embedded Case Management Model Leads to Measurable Improved Outcomes & Reducing Heart Failure Readmissions with a Complex Care Team

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