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Collaborative Case Management Issue 95

Publication Date: 3/5/2025


Abstract
Effective case management and improved communication are critical to reducing patient length of stay and preventing readmissions. One promising approach to enhancing these outcomes is the implementation of a Discharge Complexity Score (DCS), which identifies the factors that contribute to a complex discharge process. This scoring tool typically incorporates three key components: medical complexity, social determinants of health, and post-discharge care needs. Early identification of complex discharges using a DCS can benefit healthcare systems by enabling timely interventions and targeted resource allocation, leading to more efficient case management. Furthermore, predicting potential outcomes such as reduced readmission rates can be achieved by integrating a discharge complexity screening tool with an electronic hand-off system. The use of an electronic hand-off tool not only enhances communication between healthcare providers but also ensures that critical patient information is efficiently transferred, ultimately improving care coordination across the continuum. Through this dual approach—discharge complexity screening and improved communication via electronic tools—healthcare systems can achieve better patient outcomes, reduced length of stay, and decreased readmission rates.


Learning Objectives

Improving Case Management Efficiency and Length of Stay through a Discharge Complexity Score
1. Identify three key components of a discharge complexity scoring tool.
2. Examine two benefits to early identification of complex discharges.
3. Predict one potential outcome from implementing a discharge complexity screening tool.


Utilizing an Electronic Hand-off Tool to Improve Communication and Reduce Readmissions Across the Continuum of Care
1. Discuss the benefits of the hand-off tool in the electronic medical record for post-acute services.
2. Review the design methodology and outcomes of the study to evaluate the impact of the electronic medical hand-off tool on readmissions.
3. Apply what is learned to nursing practice across the continuum of communication and the tools in electronic health records.


Case Management for Integrated Care of Older People with Frailty in Community Settings (Review) – Part 2
1. Assess the effects of case management for integrated care of older people living with frailty compared with usual care.
2. Evaluate an intervention using case management as a strategy for integrated care.
3. Examine the meanings of frailty and how they relate to case management strategies.


Speakers:
Amanda Hargrove, DNP, RN, CMAC, ACM, NE-BC

Amanda Hargrove DNP, RN, CMAC, ACM, NE-BC is a Registered Nurse of 28 years. Amanda has devoted 18 years of her nursing practice to acute care case management and is currently the Sr. Director for inpatient Case Management and Utilization Review Services at ECU Health serving eastern North Carolina where she has been employed for over 36 years. Amanda specializes in leadership, has a passion for case management and hospital operations and loves working with team members on challenging complex cases.

Renee Bremer, DNP, RN, ACM, CENP

Renee Bremer recently completed her DNP in Executive Leadership and is the Associate Director for Care Management at the University of Michigan Hospital, Michigan Medicine, Ann Arbor, Michigan. She has focused her quality improvement projects on discharge checklists, readmissions, and electronic handoff tools across the continuum of care, and most recently hospital care at home.

Sadler E, Khadjesari Z, Ziemann A, Sheehan KJ, Whitney J, Wilson D, Bakolis I, Sevdalis N, Sandall J, Soukup T, Corbett T, Gonçalves-Bradley DC, Walker DM



Keywords: case management efficiency, case management, electronic hand-off tool, readmissions, integrated care, care transitions, continuum of care

Collaborative Case Management Issue 95

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