Part Four: Beyond Basics of Case Management Five-Part Series (ODW5012PT4)-Beyond Basics of Case Management Five-Part Series, Part Four Recording

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Video Summary

Dr. Toni Sesta, a founding partner of Case Management Concepts, LLC, led a comprehensive session on the evolving landscape of case management. Her consulting firm specializes in designing, implementing, and evaluating case management models, and she boasts over 25 years of research experience, particularly in congestive heart failure and fractured hip patient care. The discussion began with the clarification of current Medicare requirements, particularly the three-day stay rule for transitioning patients to skilled nursing facilities, highlighting efforts by case management professionals like Dr. Ronald Hirsch to streamline these transitions through specific documentation practices.<br /><br />Dr. Sesta emphasized the significance of transitions of care, which are often conflated with discharge planning, delineating the specific roles they play in the continuum of care—a complex and robust system that integrates various healthcare levels. She detailed how successful case management across the continuum can lead to reduced healthcare costs, shorter hospital stays, fewer admissions, and better patient outcomes. Key strategies include improved communication between inpatient and outpatient providers, using continuum care strategies like bundle payments and accountable care organizations to ensure quality and cost-efficiency.<br /><br />Dr. Sesta advocated for integrating case management roles at various transition points within healthcare, employing strategies like transitions case managers to maintain continuity and patient engagement. She discussed social determinants of health and the importance of integrating patients' physical, social, and mental health needs into their care plans.<br /><br />The session also covered potential solutions to transition challenges, particularly focusing on the need for effective team coordination and communication, especially during patient handoffs. The importance of standardized handoff protocols was underscored to avoid the errors and inefficiencies associated with poor transitions. Dr. Sesta concluded by reiterating the significance of case management as a vital component across the continuum of care, envisioning a future with increased electronic communication, integrated health systems, and a focus on patient-centered care without walls.

Keywords

case management

transitions of care

Medicare requirements

continuum of care

patient outcomes

communication strategies

social determinants of health

transition challenges

standardized handoff protocols

integrated health systems

patient-centered care

Dr. Toni Sesta

healthcare costs

care coordination