CMS’ Chronic Care Management service is aimed at strengthening access to chronic care management services in primary care settings while reducing costs, and a report on the program prepared by Mathematica Policy Research for CMS indicates its doing just that.
Many case managers have been working to forge ties with community groups in an effort to help patients maintain their health once they leave the hospital. But do these ties with community-based organizations help keep patients out of the hospital?
Transitions of care are a time when lapses can occur and problems can arise. Transfers are one of those transitions, and asking the right questions can help ensure problems aren’t overlooked, including ones that could later interfere with quality.
Jerry and Bob are twins who, up until six months ago, lived with their mother. When she died suddenly and her home was foreclosed, the two brothers found themselves homeless. Neither of them has a job, and both are disabled: Jerry has a physical injury caused by a past construction job, and Bob has severe cardiac disease. On the coldest night of the fall season, Bob is stricken with severe chest pain that is unrelieved by oral nitroglycerin.
By asking difficult questions early in a patient’s care about issues such as housing, food security, and neighborhood crime, case managers can combat common transition-related issues in high-cost or high-need patients.
