June 10, 2025 • 27 mins
Case management represents the invisible thread that weaves together all aspects of patient care in home health and hospice settings—yet many clinicians receive minimal training in this critical skill.
The conversation between Jennifer Kennedy and Kim Skehan dives deep into what effective case management looks like and why it matters so profoundly for both patient outcomes and regulatory compliance. As Kim notes, "Case management is a next level skill" that requires dedicated training and support beyond what most clinicians receive in their professional education. Organizations must invest in developing these capabilities, recognizing that quality case management takes months—not days—to cultivate.
Beyond simply making visits, case management involves comprehensive assessment, holistic care planning, and coordination across disciplines to address all patient needs. When done well, it improves patient outcomes, prevents complications, and creates seamless care transitions. When it falters, the consequences can be severe, with many survey findings at the condition level or immediate jeopardy stemming directly from coordination failures. This reality highlights the intersection where compliance meets quality—where doing right by patients simultaneously protects organizations from regulatory challenges.
With increasing patient acuity in home-based care, case management has become more complex and demanding. Today's case managers must effectively coordinate multidisciplinary teams, manage high-complexity patients, and ensure comprehensive documentation of all care activities. While technology and AI provide increasingly valuable support tools, the human elements of assessment, coordination, and communication remain irreplaceable. The most successful organizations combine robust training programs with clear processes and adequate time allowances for this vital function.
Ready to strengthen your organization's case management practices? Explore CHAP's Center for Excellence for resources, educational offerings, and disease program certifications that can enhance your team's ability to deliver truly coordinated, patient-centered care.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Greetings and salutations.
I'm Jennifer Kennedy, the leadfor quality and compliance at
CHAP, and welcome to CHAPcast.
So what we're going to talkabout today is the importance
and role of case management inboth home health and hospice,
and this whole concept of goodcase or care management is
(00:27):
really important for each andevery patient.
You know, it can make theexperience great or it can make
the experience meh, and it'salso really important to
coordinate with the rest of theeither the home health team or
the hospice team for each andevery patient.
I am so glad to be talkingabout this topic with my
(01:16):
colleague and good friend, kimSkehan.
What do you think, kim?
Are we going to tear it up withcase management?
Are we going to tear it up withcase management?
Speaker 2 (01:24):
Absolutely, and you know I have said this for many
years.
Case management is a topic nearand dear to my heart from the
time I was a clinician in thefield.
Through manager and leadershipand certainly with survey, we
(01:46):
know that effective casemanagement is vital but often
underutilized, a component thatreally supports optimal patient
management.
And, from a survey perspective,many of our survey findings, as
you know, Jennifer, at thestandard level or condition
level and even sometimesimmediate jeopardy, are related
to care planning, assessment,follow-up and updates and
(02:07):
coordination of care, whereaspects of the patient's care
were not addressed or followedup or reported and therefore
care delivery is impacted andthen at times results in actual
or potential negative outcomes.
(02:27):
So it's really important thathome health agencies and
hospices understand casemanagement.
We know that both the stateoperations manuals for home
health and hospice do discusscoordination of care, the
importance of the RN or, in homehealth, therapist in
(02:49):
coordinating and leading careand ensuring that the patient's
needs are being met.
All aspects, not just the woundthat the nurse is going in to
see or, you know, the exercisesthat are being provided by the
therapist, that we really haveto make sure that those needs
are being met.
And hospice and I think I'lltag over to you when we talk
(03:14):
about hospice, you know, has iteasier because we have an
embedded IDG requirement.
But at this point, with caredelivery, most home health
agencies should also have acomponent of interdisciplinary
team coordination.
Speaker 1 (03:31):
You know, kim, I think you're right.
I think, when I think aboutcase management and you know the
time that I spent in the fieldand when I've sort of moved on
and have been talking toproviders out there that concept
of case management and gettingit right it's hard Because
(03:52):
that's, you know, casemanagement's not a skill you're
necessarily going to learn.
Either you know social workschool or nursing school, and
when you come to an organizationthat you're going to work for,
then it's really a you know onuson the organization for them to
teach you what good casemanagement looks like for them.
(04:16):
But you know, I feel like casemanagement well, really
home-based care overall is likea gap when you're talking about
the whole schooling piece ofdifferent disciplines and in
terms of home health and hospice, it's really really important.
If we're going to say we're anorganization that does
(04:39):
patient-centered care, then wehave to case manage all of that
care so it meets the whatmatters for that patient.
Speaker 2 (04:49):
Absolutely and to your point, case management is a
learned skill and not everyvisit clinician can be a case
manager.
So, as an organization, reallyunderstanding how your operation
wants to optimize, you know theskills of a case manager, of an
(05:12):
RN or therapist in home healthas a case manager, to really
whether it's a case manager wholeads, you know several patients
and manages the care, or if itis the primary care clinician in
the home.
Like I said, in home healththey identify the clinical
manager with thoseresponsibilities, but the
(05:34):
reality is that it is theclinician in the field who is
observing, coordinating,identifying any additional
assessment and care plan needs.
And also, to your point, if youhave a clinician who's new to
home health or hospicecommunity-based care, that takes
(05:57):
time to be able to understand.
Not just the aspects of what Ineed to do for a visit, what I
need to do for regulation, right, for documentation.
Case management is a next levelskill that you can't.
It really isn't something thatcan be, you know, given or
instructed to a new staff memberon day, you know, day five or
(06:21):
day 10.
Right, right, you know day fiveor day 10, right, right, really
have to look longer, you know,into the clinicians orientation
and training.
You know three months, sixmonths and revisit it.
Speaker 1 (06:35):
Yeah, you know, and I don't know if many
organizations spend the timethat they need to in their
onboarding and that first I'llsay year that they bring
somebody on and reallyhand-holding them through.
(06:55):
Okay, this is what it means tobe a case manager and this is
the framework we use and this iswhy we do it and all of those
things, and it's probably.
If someone out there listeninghas a good formula, please email
us and let us know.
We would love to hear about it,but I think that's probably a
performance improvement area formany providers, absolutely so.
(07:23):
When we talk about theimportance of case management,
kim, why is this so important?
To get this particular, as yousay, learn skill down.
Speaker 2 (07:36):
Well, remember that home health or hospice or any
care setting the goal isholistic care and ensuring that
(07:58):
all patient needs are being metcare such as medication
management, psychosocial needs,maybe some you know mobility
needs or mentation that needsthat would be benefited by
referring to another disciplineor not knowing what the other
disciplines are.
(08:18):
The goals of care for the otherdisciplines are.
We also have seen situationswhere there are patients who are
behavioral health patientsprimarily, who their medical
needs may not be met because thefocus is on behavioral health.
But we also see it vice versa,right, those patients who we
(08:38):
have the medical needs butthey're again psychosocial or
the mental health needs are noteffectively being cared for or
addressed as well as the carecoordination and care
transitions.
You know it's so important tomake sure that there is evidence
of that coordinating care, notjust internally but with any
(09:01):
external resources that are alsosupporting the patient,
including the physicians.
And, most importantly, it'sreally for the potential for
improved outcomes for thepatient.
And again, looking at whatmatters to the patient when we
look at age-friendly care athome and knowing who's on.
(09:23):
I call it knowing who's onfirst right.
Speaker 1 (09:26):
Who's?
Speaker 2 (09:26):
on first, knowing and coordinating each team member's
goals, as well as the patient'sgoals or family goals, and not
just the specific disciplineintervention, and connecting
those dots and documenting.
Speaker 1 (09:41):
Yeah, document, document, document, for sure.
You know, and CMS has said foryears, a lot of years, that you
know one of their target areaswas, or transitions in care,
where they feel like that pointin a patient's health care is a
(10:02):
potentiality for low quality tohappen.
So when we fast forward thenand look at case management, if
we're doing good case management, then you're supporting them to
pick up the thread from oneprovider type to your provider
type so that there isn't a gap,essentially, and a potentiality
(10:25):
for drop in quality.
So, yes, it's the right thingto do, but also from a
compliance standpoint.
Cms has been watching this fora lot of years and it continues
to be an item of watching, so Idon't know if we're, as a
healthcare continuum, quitegetting it right.
Speaker 2 (10:48):
No, I would agree with that for sure.
Speaker 1 (10:52):
And when you're talking about key considerations
for those primary nurses andtherapists when managing
patients and families.
What are you thinking whenyou're talking about key
considerations?
Speaker 2 (11:09):
That's a great question.
So when it comes to casemanagement and care management
right of the patient, we arelooking at what I'm really
talking about, looking beyond,just again, the interventions on
the care plan, looking morebroadly at the needs of the
patient and coordinating thatcare and being aware of the
(11:31):
services that are being providedin that home to support the
patient.
Many times I can tell you,being in the field and with
agencies, when the clinicians inthe home are not aware of what
other disciplines are in thehome and what those goals of
care are.
So that's happened morefrequently than we'd like to see
(11:53):
.
And again, also, those timeswhen there are, you know the
dots aren't being connected interms of potentially negative
outcomes or areas that needadditional follow-up.
So that assessment, the careplanning, the facilitation of
care and services, coordinationand evaluation and advocacy for
(12:15):
the patient is extremelyimportant and that good case
management supports patient andfamily, effective
self-management when appropriateand continuity of care that
contributes to a good patientexperience.
Speaker 1 (12:32):
So, you know, I think it's fair to say that sort of
the nuts and bolts of casemanagement in home health and
hospice kind of remain the same,and they have over the years.
But there are subtle changesbecause of course healthcare has
been changing, you know.
And when we think about thingslike AI and how that's going to
(12:55):
impact case management, what areyour thoughts about that?
Speaker 2 (13:02):
I think that from a documentation standpoint, there
actually are benefits, right tobe able to have these integrated
EMR, you know systems where wecan easily view, or more
certainly more easily than along time ago, in terms of
knowing what the care is that'sbeing provided, what the goals
(13:23):
are, what the care plans are.
We have integrated care plans AIyou know it's early in the game
but certainly I can say thatfrom what I've seen and what
we've seen you know here at CHAPis there is absolute progress,
you know, and opportunity fororganizations to be able to use
(13:43):
AI to be able to capture across,you know, across the patient's
care, what you know, any areasthat may fall out.
And also, I think it can alsoassist with some of the
oversight, because one of thekey components is we're relying
on the clinicians in the fieldto assess, identify, report,
(14:07):
observe and document andcommunicate.
And we want to make sure thatthere is that oversight
component within theorganization, whether it's the
clinical manager or qualitysomeone is looking to, or IDG,
in the case of hospice right, islooking to, or IDG, in the case
(14:27):
of hospice right, someone islooking to make sure that the
dots are being connected, notjust at the time of I'll use
hospice as an example IDG, youknow, every 15 days, minimally
every 15 days, but what I calland I'll give a shout out to
Dave Matthews, but what I calland I'll give a shout out to
(14:50):
Dave Matthews, the space betweenwhich is the space between
those visits, right, that inthat documentation, is where, on
hindsight, right when you'rereviewing, you can see where
there were opportunities, youknow, for the team to be able to
, or the case manager to be ableto affect, to address some
potential issues.
Speaker 1 (15:08):
So do we agree that good case management equals
better outcomes?
Speaker 2 (15:16):
Absolutely yes.
I do believe that I've seenthat not just from a patient
standpoint.
I've seen that not just from apatient standpoint but a patient
health and safety, but alsofrom survey.
Because again, when we look atsurvey, negative findings, again
typically at the conditionlevel or potentially IJ,
(15:39):
immediate jeopardy most of thetime it evolves around
comprehensive assessment, careplanning, updates and meeting
the patient's needs.
Speaker 1 (15:50):
Exactly, and I think.
Just another item to throw inhere is patient acuity.
If there's a higher patientacuity, it's going to take more
intensive care, management orcase management to ensure you
know the patient has everythingthat they need and all those
threads are under control.
(16:11):
And I, you know, I think, or Ihope, that providers out there
do adjust productivity foracuity, because there's a lot
riding on it, like you say youknow, of course we've's a lot
riding on it.
Like you say you know, ofcourse we've got patient
outcomes riding on it.
We have larger things likesurvey riding on it.
Even audits potentiality withthe documentation, outcomes of
(16:37):
an audit can ride on.
Good case management as well.
Yep, absolutely so.
When we think about asking ourlisting population out there to
step up to the plate and fairlyevaluate, you know, the case
(17:02):
management practices of theirstaff, what are some things that
they could be asking or lookingat?
Speaker 2 (17:13):
Again, an organization.
The goal is really to adopt aninterdisciplinary care
management model that reinforcescare coordination and managing
the patient, not just makingvisits.
And even in hospice, where wehave a prescripted or designated
IDG, there still is opportunityfor the team to be able to, you
(17:37):
know, come together and reallymap out, identify the patient
care needs all of them andensure that they're meeting
those needs or coordinating theneed to meet those needs.
But in looking for anorganization determining your
processes to ensure effectivecase management in the field,
(17:57):
looking at what that role means,remember case management is
registered nurse or therapist,registered nurse for hospice, rn
or therapist for home health.
And we know that I'm going togive social workers a shout out
because they have casemanagement in their realm, they
(18:18):
have a down pat and theyunderstand.
So really, clinicians, homehealth and hospice nurses and
therapists can learn from theircolleague, their social work
colleagues and therapists ingeneral do a nice job with
therapy only and communicatingwith each other.
It's identifying those othercare needs, potential nursing,
(18:39):
et cetera.
And again, just rememberingthat LPNs, as much as they are
wonderful and a wonderful, youknow, aspect to the team, they
are not, by scope of practice,case managers.
So making sure that if they aremaking those visits, that there
is that you know thecommunication and the
(19:00):
coordination to the RN as well.
So, looking at who isperforming case management, who
do you expect to perform casemanagement in your organization?
And if it's every RN who is,you know, managing their
caseload, then you need to makesure that they have the skills
and the resources to be able tounderstand all of the aspects of
(19:24):
case management you know, andwhat that reporting, what that
looks like to manage the needsof the patient, what your
infrastructure is forinterdisciplinary team or IDG
and for oversight.
Speaker 1 (19:43):
Yeah, I couldn't agree with you more.
And I again, it circles backwhen you say all these things to
did the organization first ofall, if they're bringing
somebody in, assess thatperson's case management skills
right and, additionally, teachthem what they, that they, that
(20:05):
organization feels casemanagement encompasses, and
supporting them.
You know case management is noteasy, as you know.
You've done it, I've done it.
You know, depending on whatyour caseload looks like, it can
be really difficult and timeconsuming.
Speaker 2 (20:22):
And you know what.
You bring up a great point inaddition to productivity,
especially for those that arecase managers versus visit
clinicians cas, you know, theall of the aspects of, of the
(20:47):
patients that they have assignedto them and another.
I just want to say also thatthis is there are many resources
that are in place to that areavailable to be able to provide
case management skills or skillsof the home health or hospice
clinician, one in particular,but there are many, but one in
(21:10):
particular I do want to note isTina Morelli's books, her
handbooks, because and I will,I'm shouting out to those
particular resources becausemany years ago and still today,
you know, they have been usedfor clinicians in training, you
(21:31):
know, for case management andfor care planning and assessment
.
I've used them in the field,I've used them as a clinical
instructor, I've used them, youknow, certainly as a manager.
But again, there are otherresources as well, but you
really you don't have to startfrom zero, right, there are
resources.
(21:52):
And again, I'm giving a little.
The reason I also mentionedTina is because I know that you
also have authored, co-authored,one of her, one of her, the
hospice book, correct?
Speaker 1 (22:04):
Yeah, absolutely.
You know it's an honor to haveworked on two books with Tina.
She's a legend, honestly, butyou know she gets it and she's
able to sort of translate whatcase management should look like
in her red book and her hospicebook as well, for sure.
Speaker 2 (22:22):
And again there are other resources, you know that
are available but I would highlyencourage agencies to identify
resources for training, foroversight, you know, and for
guidance.
Identified the basics right ofhome health or hospice care and
(22:49):
then mastering the skills ofcase management, looking at what
I call next level casemanagement and that's really
evaluating disease managementand opportunities for, you know,
prevention of, you know, eithermanaging disease or prevention
of exacerbation of disease suchas heart failure, copd, diabetes
(23:13):
, wounds.
I know that here at CHAP wehave, through our Center for
Excellence, we have diseaseprogram certification that you
know many organizations arefinding are helping with framing
out.
If you will, the, you know, theextension of looking beyond
what I call the blinders of youknow, the intervent, the task at
(23:36):
hand.
So, looking beyond, you knowthe wound care or you know,
whatever that specific task is,that the clinician is going into
the home.
They really are lookingholistically at the patient.
Speaker 1 (23:49):
Absolutely, and those programs are a great framework
for organizations and theirstaff to follow in specific
disease pathways.
So, kim, as we wrap up, whatare some things that you would
like our listeners to take awaytoday?
What?
Speaker 2 (24:07):
are some things that you would like our listeners to
take away today.
Well, I think what we have beensaying is that case management,
or care management by homehealth and hospice clinicians
RNs, and then RNs and therapistsfor home health are, you know,
is vital.
It's a vital aspect of care tobe able to have someone connect
the dots.
If you know is vital, it's avital aspect of care to be able
(24:28):
to have someone connect the dots.
If you will make sure thatassessment is holistic and that
all of the patient needs arebeing identified and addressed,
whether they're being addresseddirectly through the agency or
they're coordinated throughanother resource.
That all needs to be documented, you know very well.
(24:51):
So communication, coordinationand documentation based on those
assessments and care planningof all team members is really
vital, and you know, in doingthis and making sure that these
processes are in place and yourstaff are trained and skilled,
(25:13):
the ultimate result is improvedoutcomes and that the goal is to
minimize patient care issuesand potential survey findings as
well.
Speaker 1 (25:28):
Exactly Great example where compliance meets quality
once again.
Speaker 2 (25:34):
So I wouldn't mind Somehow that's us that is.
Speaker 1 (25:37):
It's the handshake right.
There you go.
One hug Well it's been great totalk to you about this topic,
kim.
I know you and I could probablytalk all day about case
management.
I would like our listeners toshare this episode, as you feel
you need to, with the rest ofyour organization and explore
(26:00):
some of the resources or linksthat we have with our podcast
notes and check out our Centerfor Excellence to see if there
are any educational offeringsthat we have that might enhance
your staff's journey toproviding great case management.
So, in closing, thanks, kimagain for teaming up with me.
(26:24):
It's always a pleasure for usto talk, you know, on podcast or
off podcast.
It's always great to spend timewith you Absolutely.
And thanks to all of you outthere in podcast land for taking
time out of your day to plug into our episode about case
management From Kim, me and theentire CHAP staff.
(26:45):
Keep your quality needle movingforward, stay safe and well,
and thanks for all you do.
Thank you.
Greetings and salutations.
I'm Jennifer Kennedy, the leadfor quality and compliance at
CHAP, and welcome to CHAPcast.
So what we're going to talkabout today is the importance
and role of case management inboth home health and hospice,
and this whole concept of goodcase or care management is
(00:27):
really important for each andevery patient.
You know, it can make theexperience great or it can make
the experience meh, and it'salso really important to
coordinate with the rest of theeither the home health team or
the hospice team for each andevery patient.
I am so glad to be talkingabout this topic with my
(01:16):
colleague and good friend, kimSkehan.
What do you think, kim?
Are we going to tear it up withcase management?
Are we going to tear it up withcase management?
Speaker 2 (01:24):
Absolutely, and you know I have said this for many
years.
Case management is a topic nearand dear to my heart from the
time I was a clinician in thefield.
Through manager and leadershipand certainly with survey, we
(01:46):
know that effective casemanagement is vital but often
underutilized, a component thatreally supports optimal patient
management.
And, from a survey perspective,many of our survey findings, as
you know, Jennifer, at thestandard level or condition
level and even sometimesimmediate jeopardy, are related
to care planning, assessment,follow-up and updates and
(02:07):
coordination of care, whereaspects of the patient's care
were not addressed or followedup or reported and therefore
care delivery is impacted andthen at times results in actual
or potential negative outcomes.
(02:27):
So it's really important thathome health agencies and
hospices understand casemanagement.
We know that both the stateoperations manuals for home
health and hospice do discusscoordination of care, the
importance of the RN or, in homehealth, therapist in
(02:49):
coordinating and leading careand ensuring that the patient's
needs are being met.
All aspects, not just the woundthat the nurse is going in to
see or, you know, the exercisesthat are being provided by the
therapist, that we really haveto make sure that those needs
are being met.
And hospice and I think I'lltag over to you when we talk
(03:14):
about hospice, you know, has iteasier because we have an
embedded IDG requirement.
But at this point, with caredelivery, most home health
agencies should also have acomponent of interdisciplinary
team coordination.
Speaker 1 (03:31):
You know, kim, I think you're right.
I think, when I think aboutcase management and you know the
time that I spent in the fieldand when I've sort of moved on
and have been talking toproviders out there that concept
of case management and gettingit right it's hard Because
(03:52):
that's, you know, casemanagement's not a skill you're
necessarily going to learn.
Either you know social workschool or nursing school, and
when you come to an organizationthat you're going to work for,
then it's really a you know onuson the organization for them to
teach you what good casemanagement looks like for them.
(04:16):
But you know, I feel like casemanagement well, really
home-based care overall is likea gap when you're talking about
the whole schooling piece ofdifferent disciplines and in
terms of home health and hospice, it's really really important.
If we're going to say we're anorganization that does
(04:39):
patient-centered care, then wehave to case manage all of that
care so it meets the whatmatters for that patient.
Speaker 2 (04:49):
Absolutely and to your point, case management is a
learned skill and not everyvisit clinician can be a case
manager.
So, as an organization, reallyunderstanding how your operation
wants to optimize, you know theskills of a case manager, of an
(05:12):
RN or therapist in home healthas a case manager, to really
whether it's a case manager wholeads, you know several patients
and manages the care, or if itis the primary care clinician in
the home.
Like I said, in home healththey identify the clinical
manager with thoseresponsibilities, but the
(05:34):
reality is that it is theclinician in the field who is
observing, coordinating,identifying any additional
assessment and care plan needs.
And also, to your point, if youhave a clinician who's new to
home health or hospicecommunity-based care, that takes
(05:57):
time to be able to understand.
Not just the aspects of what Ineed to do for a visit, what I
need to do for regulation, right, for documentation.
Case management is a next levelskill that you can't.
It really isn't something thatcan be, you know, given or
instructed to a new staff memberon day, you know, day five or
(06:21):
day 10.
Right, right, you know day fiveor day 10, right, right, really
have to look longer, you know,into the clinicians orientation
and training.
You know three months, sixmonths and revisit it.
Speaker 1 (06:35):
Yeah, you know, and I don't know if many
organizations spend the timethat they need to in their
onboarding and that first I'llsay year that they bring
somebody on and reallyhand-holding them through.
(06:55):
Okay, this is what it means tobe a case manager and this is
the framework we use and this iswhy we do it and all of those
things, and it's probably.
If someone out there listeninghas a good formula, please email
us and let us know.
We would love to hear about it,but I think that's probably a
performance improvement area formany providers, absolutely so.
(07:23):
When we talk about theimportance of case management,
kim, why is this so important?
To get this particular, as yousay, learn skill down.
Speaker 2 (07:36):
Well, remember that home health or hospice or any
care setting the goal isholistic care and ensuring that
(07:58):
all patient needs are being metcare such as medication
management, psychosocial needs,maybe some you know mobility
needs or mentation that needsthat would be benefited by
referring to another disciplineor not knowing what the other
disciplines are.
(08:18):
The goals of care for the otherdisciplines are.
We also have seen situationswhere there are patients who are
behavioral health patientsprimarily, who their medical
needs may not be met because thefocus is on behavioral health.
But we also see it vice versa,right, those patients who we
(08:38):
have the medical needs butthey're again psychosocial or
the mental health needs are noteffectively being cared for or
addressed as well as the carecoordination and care
transitions.
You know it's so important tomake sure that there is evidence
of that coordinating care, notjust internally but with any
(09:01):
external resources that are alsosupporting the patient,
including the physicians.
And, most importantly, it'sreally for the potential for
improved outcomes for thepatient.
And again, looking at whatmatters to the patient when we
look at age-friendly care athome and knowing who's on.
(09:23):
I call it knowing who's onfirst right.
Speaker 1 (09:26):
Who's?
Speaker 2 (09:26):
on first, knowing and coordinating each team member's
goals, as well as the patient'sgoals or family goals, and not
just the specific disciplineintervention, and connecting
those dots and documenting.
Speaker 1 (09:41):
Yeah, document, document, document, for sure.
You know, and CMS has said foryears, a lot of years, that you
know one of their target areaswas, or transitions in care,
where they feel like that pointin a patient's health care is a
(10:02):
potentiality for low quality tohappen.
So when we fast forward thenand look at case management, if
we're doing good case management, then you're supporting them to
pick up the thread from oneprovider type to your provider
type so that there isn't a gap,essentially, and a potentiality
(10:25):
for drop in quality.
So, yes, it's the right thingto do, but also from a
compliance standpoint.
Cms has been watching this fora lot of years and it continues
to be an item of watching, so Idon't know if we're, as a
healthcare continuum, quitegetting it right.
Speaker 2 (10:48):
No, I would agree with that for sure.
Speaker 1 (10:52):
And when you're talking about key considerations
for those primary nurses andtherapists when managing
patients and families.
What are you thinking whenyou're talking about key
considerations?
Speaker 2 (11:09):
That's a great question.
So when it comes to casemanagement and care management
right of the patient, we arelooking at what I'm really
talking about, looking beyond,just again, the interventions on
the care plan, looking morebroadly at the needs of the
patient and coordinating thatcare and being aware of the
(11:31):
services that are being providedin that home to support the
patient.
Many times I can tell you,being in the field and with
agencies, when the clinicians inthe home are not aware of what
other disciplines are in thehome and what those goals of
care are.
So that's happened morefrequently than we'd like to see
(11:53):
.
And again, also, those timeswhen there are, you know the
dots aren't being connected interms of potentially negative
outcomes or areas that needadditional follow-up.
So that assessment, the careplanning, the facilitation of
care and services, coordinationand evaluation and advocacy for
(12:15):
the patient is extremelyimportant and that good case
management supports patient andfamily, effective
self-management when appropriateand continuity of care that
contributes to a good patientexperience.
Speaker 1 (12:32):
So, you know, I think it's fair to say that sort of
the nuts and bolts of casemanagement in home health and
hospice kind of remain the same,and they have over the years.
But there are subtle changesbecause of course healthcare has
been changing, you know.
And when we think about thingslike AI and how that's going to
(12:55):
impact case management, what areyour thoughts about that?
Speaker 2 (13:02):
I think that from a documentation standpoint, there
actually are benefits, right tobe able to have these integrated
EMR, you know systems where wecan easily view, or more
certainly more easily than along time ago, in terms of
knowing what the care is that'sbeing provided, what the goals
(13:23):
are, what the care plans are.
We have integrated care plans AIyou know it's early in the game
but certainly I can say thatfrom what I've seen and what
we've seen you know here at CHAPis there is absolute progress,
you know, and opportunity fororganizations to be able to use
(13:43):
AI to be able to capture across,you know, across the patient's
care, what you know, any areasthat may fall out.
And also, I think it can alsoassist with some of the
oversight, because one of thekey components is we're relying
on the clinicians in the fieldto assess, identify, report,
(14:07):
observe and document andcommunicate.
And we want to make sure thatthere is that oversight
component within theorganization, whether it's the
clinical manager or qualitysomeone is looking to, or IDG,
in the case of hospice right, islooking to, or IDG, in the case
(14:27):
of hospice right, someone islooking to make sure that the
dots are being connected, notjust at the time of I'll use
hospice as an example IDG, youknow, every 15 days, minimally
every 15 days, but what I calland I'll give a shout out to
Dave Matthews, but what I calland I'll give a shout out to
(14:50):
Dave Matthews, the space betweenwhich is the space between
those visits, right, that inthat documentation, is where, on
hindsight, right when you'rereviewing, you can see where
there were opportunities, youknow, for the team to be able to
, or the case manager to be ableto affect, to address some
potential issues.
Speaker 1 (15:08):
So do we agree that good case management equals
better outcomes?
Speaker 2 (15:16):
Absolutely yes.
I do believe that I've seenthat not just from a patient
standpoint.
I've seen that not just from apatient standpoint but a patient
health and safety, but alsofrom survey.
Because again, when we look atsurvey, negative findings, again
typically at the conditionlevel or potentially IJ,
(15:39):
immediate jeopardy most of thetime it evolves around
comprehensive assessment, careplanning, updates and meeting
the patient's needs.
Speaker 1 (15:50):
Exactly, and I think.
Just another item to throw inhere is patient acuity.
If there's a higher patientacuity, it's going to take more
intensive care, management orcase management to ensure you
know the patient has everythingthat they need and all those
threads are under control.
(16:11):
And I, you know, I think, or Ihope, that providers out there
do adjust productivity foracuity, because there's a lot
riding on it, like you say youknow, of course we've's a lot
riding on it.
Like you say you know, ofcourse we've got patient
outcomes riding on it.
We have larger things likesurvey riding on it.
Even audits potentiality withthe documentation, outcomes of
(16:37):
an audit can ride on.
Good case management as well.
Yep, absolutely so.
When we think about asking ourlisting population out there to
step up to the plate and fairlyevaluate, you know, the case
(17:02):
management practices of theirstaff, what are some things that
they could be asking or lookingat?
Speaker 2 (17:13):
Again, an organization.
The goal is really to adopt aninterdisciplinary care
management model that reinforcescare coordination and managing
the patient, not just makingvisits.
And even in hospice, where wehave a prescripted or designated
IDG, there still is opportunityfor the team to be able to, you
(17:37):
know, come together and reallymap out, identify the patient
care needs all of them andensure that they're meeting
those needs or coordinating theneed to meet those needs.
But in looking for anorganization determining your
processes to ensure effectivecase management in the field,
(17:57):
looking at what that role means,remember case management is
registered nurse or therapist,registered nurse for hospice, rn
or therapist for home health.
And we know that I'm going togive social workers a shout out
because they have casemanagement in their realm, they
(18:18):
have a down pat and theyunderstand.
So really, clinicians, homehealth and hospice nurses and
therapists can learn from theircolleague, their social work
colleagues and therapists ingeneral do a nice job with
therapy only and communicatingwith each other.
It's identifying those othercare needs, potential nursing,
(18:39):
et cetera.
And again, just rememberingthat LPNs, as much as they are
wonderful and a wonderful, youknow, aspect to the team, they
are not, by scope of practice,case managers.
So making sure that if they aremaking those visits, that there
is that you know thecommunication and the
(19:00):
coordination to the RN as well.
So, looking at who isperforming case management, who
do you expect to perform casemanagement in your organization?
And if it's every RN who is,you know, managing their
caseload, then you need to makesure that they have the skills
and the resources to be able tounderstand all of the aspects of
(19:24):
case management you know, andwhat that reporting, what that
looks like to manage the needsof the patient, what your
infrastructure is forinterdisciplinary team or IDG
and for oversight.
Speaker 1 (19:43):
Yeah, I couldn't agree with you more.
And I again, it circles backwhen you say all these things to
did the organization first ofall, if they're bringing
somebody in, assess thatperson's case management skills
right and, additionally, teachthem what they, that they, that
(20:05):
organization feels casemanagement encompasses, and
supporting them.
You know case management is noteasy, as you know.
You've done it, I've done it.
You know, depending on whatyour caseload looks like, it can
be really difficult and timeconsuming.
Speaker 2 (20:22):
And you know what.
You bring up a great point inaddition to productivity,
especially for those that arecase managers versus visit
clinicians cas, you know, theall of the aspects of, of the
(20:47):
patients that they have assignedto them and another.
I just want to say also thatthis is there are many resources
that are in place to that areavailable to be able to provide
case management skills or skillsof the home health or hospice
clinician, one in particular,but there are many, but one in
(21:10):
particular I do want to note isTina Morelli's books, her
handbooks, because and I will,I'm shouting out to those
particular resources becausemany years ago and still today,
you know, they have been usedfor clinicians in training, you
(21:31):
know, for case management andfor care planning and assessment
.
I've used them in the field,I've used them as a clinical
instructor, I've used them, youknow, certainly as a manager.
But again, there are otherresources as well, but you
really you don't have to startfrom zero, right, there are
resources.
(21:52):
And again, I'm giving a little.
The reason I also mentionedTina is because I know that you
also have authored, co-authored,one of her, one of her, the
hospice book, correct?
Speaker 1 (22:04):
Yeah, absolutely.
You know it's an honor to haveworked on two books with Tina.
She's a legend, honestly, butyou know she gets it and she's
able to sort of translate whatcase management should look like
in her red book and her hospicebook as well, for sure.
Speaker 2 (22:22):
And again there are other resources, you know that
are available but I would highlyencourage agencies to identify
resources for training, foroversight, you know, and for
guidance.
Identified the basics right ofhome health or hospice care and
(22:49):
then mastering the skills ofcase management, looking at what
I call next level casemanagement and that's really
evaluating disease managementand opportunities for, you know,
prevention of, you know, eithermanaging disease or prevention
of exacerbation of disease suchas heart failure, copd, diabetes
(23:13):
, wounds.
I know that here at CHAP wehave, through our Center for
Excellence, we have diseaseprogram certification that you
know many organizations arefinding are helping with framing
out.
If you will, the, you know, theextension of looking beyond
what I call the blinders of youknow, the intervent, the task at
(23:36):
hand.
So, looking beyond, you knowthe wound care or you know,
whatever that specific task is,that the clinician is going into
the home.
They really are lookingholistically at the patient.
Speaker 1 (23:49):
Absolutely, and those programs are a great framework
for organizations and theirstaff to follow in specific
disease pathways.
So, kim, as we wrap up, whatare some things that you would
like our listeners to take awaytoday?
What?
Speaker 2 (24:07):
are some things that you would like our listeners to
take away today.
Well, I think what we have beensaying is that case management,
or care management by homehealth and hospice clinicians
RNs, and then RNs and therapistsfor home health are, you know,
is vital.
It's a vital aspect of care tobe able to have someone connect
the dots.
If you know is vital, it's avital aspect of care to be able
(24:28):
to have someone connect the dots.
If you will make sure thatassessment is holistic and that
all of the patient needs arebeing identified and addressed,
whether they're being addresseddirectly through the agency or
they're coordinated throughanother resource.
That all needs to be documented, you know very well.
(24:51):
So communication, coordinationand documentation based on those
assessments and care planningof all team members is really
vital, and you know, in doingthis and making sure that these
processes are in place and yourstaff are trained and skilled,
(25:13):
the ultimate result is improvedoutcomes and that the goal is to
minimize patient care issuesand potential survey findings as
well.
Speaker 1 (25:28):
Exactly Great example where compliance meets quality
once again.
Speaker 2 (25:34):
So I wouldn't mind Somehow that's us that is.
Speaker 1 (25:37):
It's the handshake right.
There you go.
One hug Well it's been great totalk to you about this topic,
kim.
I know you and I could probablytalk all day about case
management.
I would like our listeners toshare this episode, as you feel
you need to, with the rest ofyour organization and explore
(26:00):
some of the resources or linksthat we have with our podcast
notes and check out our Centerfor Excellence to see if there
are any educational offeringsthat we have that might enhance
your staff's journey toproviding great case management.
So, in closing, thanks, kimagain for teaming up with me.
(26:24):
It's always a pleasure for usto talk, you know, on podcast or
off podcast.
It's always great to spend timewith you Absolutely.
And thanks to all of you outthere in podcast land for taking
time out of your day to plug into our episode about case
management From Kim, me and theentire CHAP staff.
(26:45):
Keep your quality needle movingforward, stay safe and well,
and thanks for all you do.
Thank you.
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