Reducing Adverse Events in Post-discharge Transitions of Care Programs

Pat Stricker, RN, MEd

Senior Vice President

Adverse events have been tracked for years, but mostly as they relate to issues that occur during a hospitalization, or during drug or clinical trials.  Adverse events refer to harm from medical care rather than underlying disease and are defined as:

  • “an injury that was caused by medical management (rather than the underlying disease) and that prolonged the hospitalization, produced a disability at the time of discharge, or both.”
  • “an unintended physical injury resulting from or contributed to by medical care (including the absence of indicated medical treatment), that requires additional monitoring, treatment, or hospitalization, or that results in death.”
  • “any unfavorable and unintended sign (e.g., an abnormal laboratory finding), symptom, or disease temporarily associated with the use of a drug, without any judgment about causality or relationship to the drug.” (Used in drug and clinical trials)
  • An injury that occurs due to “negligent care that falls below the standards expected of clinicians in the community.”

Adverse events can be:

  • Preventable: “due to an error or failure to apply an accepted strategy for prevention” or “avoidable by any means currently available unless that means was not considered standard care.”
  • Ameliorable: “not preventable, but the severity of the injury could have been substantially reduced if different actions or procedures had been performed or followed.”

While numerous studies have been conducted to identify adverse events occurring during hospital stays and trials, there are only a few that address adverse events that occur after a patient is discharged from the hospital and transitioned to home or an outpatient facility. Because the process of transitioning a patient from a hospital setting to home can lead to patient safety and quality issues if not done correctly, more emphasis needs to be placed on trying to study and identify the causes for post-discharge adverse events.


Statistics on Post-discharged Adverse Events

A 2003 study found that nearly one in five patients (76 of 400 patients) suffered adverse events within 5 weeks of being discharged from the hospital to home. Of these:

  • 5% were found to be preventable and 30.7% were ameliorable (could have been reduced in severity by changing patient care procedures).
  • All were identified as being caused by “system problems in the hospital”, with 60% due to communication problems between the hospital staff and the patient or primary care physician.
  • The most common problems were related to drugs (66%), many of which could have been avoided or mitigated. Another 17% were related to medical procedures.

A study of elderly patients found that 14.1% had one or more medication discrepancies, resulting in 14.3% of the patients being re-hospitalized within 30 days. 49.2% of the discrepancies were categorized as “system” issues.

Another study found that nearly 40% of patients are discharged with test results pending and 10% of these require some action. A similar number are discharged with orders to complete a diagnostic workup as an outpatient, placing them at risk if the workup is not completed in a timely manner or  not done at all.

In addition, literature reviews identified other issues related to adverse events:

  • Two-thirds of post-discharge adverse events are due to medications. The other one-third involve nonsurgical procedures, therapeutic errors, hospital acquired infections, diagnostic errors, pressure ulcers, and falls.
  • Most of the adverse events are either preventable or could have been reduced in severity.
  • Nearly 20% of Medicare patients are re-hospitalizedwithin 30 days of discharge, making post-discharge adverse events a high priority for the US healthcare system.
  • Rural patients are most vulnerable for adverse events because they may not receive timely follow-up care by a local provider after discharge or may not have an electronic health record, causing an information transfer delay.



The studies have provided good insight into many of the causes of post-discharge adverse events and further studies will help us focus on them in more detail. However, changes in the overall healthcare system over the past 15-20 years have also caused significant effects, both positively and negatively, in our delivery of care processes.

  • The average length of a hospital stay has been significantly reduced, resulting in transferring tasks and procedures that would have previously been done in the hospital to the patient’s home after discharge. These now become the responsibility of the patient, family, caregiver, or home care providers.
  • Hospitalists now manage patients while in the hospital and then transfer the care back to the patient’s primary physician upon discharge. This can be a benefit if one of the physicians notices something that is overlooked by another. However this can also cause a lack of continuity of care, if discharge summaries or discussions with the primary care physician are not done at the time the care is being transferred. A delay in information transfer or faulty communication can result in adverse events.
  • The advent of the Medical Home model has provided a patient-centered, comprehensive model in which physicians assume responsibility for their patient’s overall healthcare and coordination of his/her care across the continuum, regardless of the setting. However, in order for this to work, good communication among all team members is essential, and unfortunately lack of timely communication is often an issue.

This communication issue is highlighted in a summary of the literature conducted by the Society of Hospital Medicine/Society of General Internal Medicine Task Force. They found that lack of communication adversely affects post-discharge care transitions.

  • Direct communication between hospital physicians and the primary care physicians occurs in only 3-20% of cases.
  • A discharge summary is only available 12-34% of the time for the first post-discharge visit and on 51-77% of the time 4 weeks after discharge. This delay affected the quality of care in about 25% of the follow-up visits.
  • Discharge summaries often lack key information, e.g. discharge medications, treatments, hospital summary, diagnostic test results, pending test results, follow-up plans, and patient or family counseling.
  • In addition to lack of communication and continuity among providers and the lack of timely, accurate, detailed discharge summaries, the following problems were also noted as reasons for post-discharge adverse events:
    • Lack of accurate, up-to-date medication reconciliation causing medication discrepancies
    • Inaccurate assessments of the patient’s ability to care for themselves after discharge
    • Failure to plan for appropriate resources to help the patient with the transition to home
    • Inability of rural patients to follow-up in a timely manner with their local provider due to distance and lack of transportation

Strategies and Recommendations

As a result of studies and the attention being focused on transitions of care, numerous care recommendations have been identified to help reduce adverse events. For organizations developing a post-discharge transition of care program, the following key strategies should be incorporated in the program to make it successful:

  • Primary care physicians need to be contacted at the time of discharge and provided with key elements of the discharge summary, medication changes, significant lab results or pending tests, new treatments, and follow-up plans.
  • A nurse needs to be assigned to manage the overall post-discharge process for patients.
  • A clinical pharmacist should be part of the healthcare team to follow-up with patients within five days after discharge to review medications and assess for potential problems.
  • All team members must be held accountable for their share of the care transition process. They must carry out their responsibilities and assure that nothing “falls through the cracks”.
  • Medication reconciliation must be done to ensure chronic medications were not stopped and new medications are safe.
  • Care transition interventions should be patient-specific, such as goal-oriented patient goals, conducting follow-up phone calls, and linking patients to community resources.
  • Education for patients and their families to assure they understand their diagnosis, changes in medication therapy, follow-up instructions, changes in drug therapy, and who to contact with questions or problems. This should be done prior to discharge and again after discharge once they reach their home or outpatient facility.
  • Principles recommended by the Transitions of Care Consensus Policy Statement (TOCCC), developed as a joint collaboration by 6 physician organizations/associations. These principles address quality gaps in transitions between inpatient and outpatient settings and should be included in transition of care programs: accountability; coordination of care; involvement of the patient and family member; all patients and their family/caregivers should have a medical home or coordinating clinician; patients and/or their family/caregivers need to know who is responsible for their care at every point in the care transition; and national standards with standardized metrics that lead to quality improvement and accountability.
  • Standards developed by the TOCCC describe components needed for implementing these principles: coordinating clinicians; care plans and transition record; communication infrastructure; standard communication formats; transition responsibility; timeliness; community standards; and measurement.
  • Health information technology (HIT) applications are also essential to being able to effectively communicating and disseminating information to all members of the healthcare team.

NOTE: Next month’s article will go into detail on the types of HIT that should be considered and how it can be used to improve the post-discharge care transition process.  


Additional Resources and Tools

For those interested in developing a post-discharge transition of care program, the following sites provide helpful resources and tools. The first two resources are documents that definitely should be reviewed.

  • NTOCC’s Position Paper (page 5) describes additional key elements needed to assure smooth, safe, and effective transitions of care. In summary they include: developing standardized processes; establishing accountability; increasing the use of case management and professional care coordination; developing performance measures; and implementing payment systems that align incentives. In addition, on page 27, NTOCC recommends developing: best practices; quality measures that reflect process standards and expected outcomes, including the patient care experience; and incentives for sharing information across all care settings, based on accountability and ultimate outcomes.
  • The Transitions of Care Consensus Policy Statement (TOCCC), developed by the American College of Physicians (ACP), Society of Hospital Medicine (SHM), Society of General Internal Medicine (SGIM), American Geriatric Society (AGS), American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM),recommends a set of data elements that should always be part of a transition record: principal diagnoses and problem list; medication list, including over the counter (OTC)/herbals, allergies, and drug interactions; clear identification of medical home/coordinating physician and contact information; patient’s cognitive status; and test results/pending results and normal value ranges and explanation for patients. In addition, they also suggest additional elements that should be included: emergency plan with person and contact number; treatment and diagnostic plan; prognosis and goals of care; advance directives, power of attorney, and consent; planned interventions, durable medical equipment, wound care, etc.; and assessment of family caregiver status.
  • The National Learning Consortium offers a resource paper, Care Coordination Tool for Transition to Long-Term and Post-Acute Care, to train and support care professionals on key clinical information needed for inclusion in care records when providing a transition of care program. It is a good overview of a care transition program and what needs to be included.
  • The American Academy of Ambulatory Care Nursing provides a toolkit that includes 18 resources and tools for the following four areas: Care Coordination and Transition Management, Risk Stratification or Assessment, Hand-Off Communication, and Patient Education.

Improving transition of care is a key safety and quality issue today in healthcare. Studies are needed to identify and analyze areas that may be able to predict the occurrence of adverse events, especially in post-discharge transitions. This will provide the data needed to develop screening tools to proactively identify post-discharge risk factors that can reduce adverse events during these vulnerable transitions of care from the hospital to home.

TCS Healthcare Technologies Launches ACUITYnxt

The newest SaaS-based case management software provides the most intuitive and adaptive experience for case managers and managed care nurses allowing them to focus on the patient, not the technology.


AUBURN, Calif., Nov. 8, 2018 /PRNewswire/ — TCS Healthcare Technologies is excited to announce the launch of ACUITYnxt, the latest generation of software products to support the care management industry.  ACUITYnxt, a web-based case management software application, offers several features that fully support the case management process and offers clients the flexibility to design workflows to suit their specific needs.

“Early in the development process, our clinical team was embedded with our software developers in the architecture of ACUITYnxt.  This has resulted in clinician-designed screens that make sense to case managers without unnecessary clicks, confusing screens, or endless searches for information,” said Deborah Keller, RN, BSN, CMCN, Chief Operating Officer for TCS.  “Case managers can quickly and easily create alerts, add notes and attachments, capture consent, and follow up on planned actions.”

In response to healthcare’s everchanging regulatory environment, ACUITYnxt is the industry’s only software platform that offers custom screen templates. Screen templates allow screen designs to adapt to regulatory changes without loss of data and costly software code rework.

“Screens can be redesigned all while maintaining the intuitive navigation that is core to ACUITYnxt and demonstrate compliance with CMS, NCQA and URAC standards,” added Keller.

ACUITYnxt offers robust security and technical features.  The application includes system controls to manage user access and to provide role-based security.  ACUITYnxt leverages end-to-end encryption and maintains an audit history.  TCS’ data center is HIPAA, HITECH, HITRUST and SOC 2 compliant, adhering to the highest healthcare security standards.

ACUITYnxt is the result of TCS’ ongoing investment to develop care management software for managed care organizations, leveraging US-based developers and clinicians.

“ACUITYnxt represents the TCS’ latest commitment to the care management industry,” said Rob Pock, CEO and Founder.  “For the past 35 years, we have focused exclusively on care management software development to support case management, utilization management, and population health.  ACUITYnxt captures our domain expertise and demonstrates our investment for growth for another 35 years.”

To request a demo of ACUITYnxt, please contact or call (530) 886-1700 x203

About TCS Healthcare Technologies (

TCS Healthcare Technologies (TCS) is a leading provider of software and clinical solutions that support and improve medical management operations for health plans and third-party administrators.  TCS’ team of US-based clinicians and developers are recognized for their best-in-class managed care expertise and customer support throughout the industry.

To learn more about ACUITYnxt and TCS Healthcare Technologies, visit

healthcare white paper notes

Hospital Readmissions and Emergency Medicine Over-Utilization

Hospital Readmissions and Emergency Medicine Over-Utilization

Author: Deborah Keller, COO, RN, BSN, CMCN

Despite efforts to decrease hospital readmissions showing promise, the cost for these services
continue to cost billions of dollars annually. Emergency medical systems are straining under
record-breaking call volumes. With the convergence of these challenges, community level
opportunities exist.

Download the full PDF 

JReport Powers TCS Healthcare Technologies with Advanced Embedded Analytics

TCS boosts reporting and analytics services for managed care clinicians to gather greater insights into care management performance.


JReport, the leading embedded analytics and reporting software solution, was selected as a partner by TCS Healthcare Technologies (TCS), a leading provider of managed care software and clinical content solutions. JReport will be embedded into TCS’s new ACUITYnxt software to enable advanced reporting and analytics services for managed care organizations to improve overall managed care operations.

JReport’s interactive, highly precise, self-service reporting and dashboard capabilities will provide the next level of advanced analytics for ACUITYnxt users. Specifically, ACUITYnxt clients will be empowered to interact with or even build their own aggregate reports, dashboards and letters, with ease. This will allow case managers and managed care nurses to improve the analysis of care management data and correspondence with each individual in their case load.

“We’re very excited to deliver critical reporting and analytics tools backed by a world class development and support team to assist healthcare professionals to streamline their workflows in serving patients,” said Dr. Bing Yao, CEO of Jinfonet Software. “We look forward to our continued partnership with TCS Healthcare in their mission to promote the best medical management practices and provide the most cost-effective technology solutions to support those processes.”

“JReport brings a highly customizable, sophisticated reporting feature set to our intuitive and adaptable care management software solution, ACUITYnxt,” said Rob Pock, CEO of TCS Healthcare Technologies. “With JReport, our clients will undoubtedly be better equipped to improve their business processes all from the convenience of ACUITYnxt, which they will be using for day-to-day care management operations.”

JReport 15.5 is now available for download. To request a customized demo, please contact info(at) or call (240) 477-1000.

ACUITYnxt is available in November 2018. To request a demo, please contact info(at) or call (530) 886-1700 x203.

About Jinfonet Software
JReport from Jinfonet Software empowers companies to embed the most precise, high performance reports and dashboards into web applications. The embedded analytics platform provides developers and users with a scalable, fault tolerant solution that’s easy to customize and work seamlessly as part of their applications on any platform, with any data source. Every day, JReport delivers insights for hundreds of thousands of users at over 10,000 OEM and enterprise installations worldwide.

More information on Jinfonet Software and JReport is available at

About TCS Healthcare Technologies
TCS Healthcare Technologies (TCS), based out of Sacramento, CA, is a leading provider of software and clinical solutions that support and improve medical management operations for health plans, specialty plans, TPAs and risk-bearing provider groups. TCS’s team of US-based clinicians and developers are recognized for their best-in-class managed care expertise and customer support throughout the industry.

To learn more about ACUITYnxt and TCS Healthcare Technologies, visit

Case Management Week: Moving Patients to Wellness

Pat Stricker, RN, MEd

Senior Vice President

Since Case Management Week is celebrated the 2nd week of October and this newsletter is released the 3rd week of the month, it seems that I always have to wish you a belated Happy National Case Management Week. However this year, I would like to take the opportunity to extend National Case Management Week to a “Month”. Why not? That way I can wish you a “Happy Case Management Month” instead of a belated Happy Case Management Week.

You deserve recognition for all the important contributions you make throughout the year! Your dedication, commitment, and passion for working with patients/clients and their families to educate, empower, and enable them to make informed decisions – moving them towards wellness. This makes a tremendous difference in their lives and is also invaluable to the health care delivery system by improving the quality, efficiency, and effectiveness of care. Case Managers act as advocates, educators, coordinators, facilitators, navigators, and resource managers to help patients/clients understand and manage their condition, find and gain access to services, and obtain high quality, cost-effective care. That sounds like it deserves a month-long recognition to me. How about you?

In addition to recognizing all case managers, I would also like to recognize and congratulate all the care management team members who support the Case Managers. Together you make a terrific team, and without your assistance the Case Managers would find it very difficult to carry out their work.

case management weeekThis year’s theme is “Moving Patients to Wellness”, which is a perfect description of what case managers have been doing for over half a century and will continue to do in the future. The role and importance of case management continues to increase each year and it has become a foundation of the health care delivery system. Case management is being used in more and more settings and types of programs. CMSA has worked diligently to ensure the role of the professional case manager is known and respected by all health care professionals, policy makers, and consumers. In addition, we must also take every opportunity to let others know what we do and how our role improves the outcomes of our patients/clients and the entire healthcare system.

The practice of case management is not easy, but it is definitely rewarding. Patients/clients and families develop personal relationships with their case manager because of their deep commitment to helping them through difficult times. The following are testimonials from patients/clients and family members relating their feelings about their case manager, their attributes, and how they have helped “move them to wellness”. I’m sure you can all relate to these comments and have probably received similar comments from your patients/clients and their families.

  1. “Know that you are doing meaningful work and helping people more than you know. I have seen you work with [patients] and believe you always try to do your best to get the best care possible.” [i]
  2. “I am not sure he would still be alive, but for his nurse’s advocacy on his behalf.”
  3. “I gained an accountability partner and a coach to help me assess my condition and set small, practical goals for myself. This helped me to achieve my greater goal of managing the disease that took the lives of family members very close and dear to me. ……has enabled me, in just one year, to make significant changes in my life.  As a result, I’ve lowered my blood sugar and for the first time, I feel in control.” [ii]
  4. “I worked one-on-one with both a nurse care manager and a registered dietician to learn how this condition [diabetes] and different foods affect my body so that I can take better care of myself. The encouragement and support I encountered …. gave me the confidence I needed to see me through my plan, and to make real changes to my diet and in my life.”
  5. “You have gone out of your way to help me understand the whole process and have guided my steps. I do hope that your company truly appreciates the gem that you are!” [iii]
  6. “She is a case manager who truly respects and advocates for her clients! She is passionate, caring and hard-working which makes her an excellent case manager who works well with all types of individuals and families.” [iv]
  7. “She is tenacious in seeking the best care for her clients and is extremely capable in using all resources to ensure the best quality care.”
  8. “I know I could not have navigated all the medical requirements and decisions without [her] guidance…… I believe that [she] and other case managers are an integral part of a successful recovery.” [v]
  9. “The person most responsible for getting my dad and mom into nursing care 2 years ago was [CM’s name]. I am convinced that without her getting dad out of the house and into [name of facility], and the subsequent care given to him by the nurses, nurse’s aides, doctor, and therapists; I would not have had these extra two years to enjoy my dad.” [vi]
  10. “I was looking for a way to get hernamed “Best [Case] Manager in the world,” when it struck me that a letter to her boss describing the water that she walked on in dealing with my brother would be a more productive use of my time.”
  11. “She is helpful, has great attention to detail, is attentive, and a good communicator. She is proactive with communication rather than reactive and she follows up.” [vii]
  12. “She is wonderful to come up with new and different ideas for helping our son achieve success in his endeavors. She is just simply a member of our family and we love her.”
  13. “She instructed me on everything I needed to do! She has taken away the stress and confusion I had over navigating [the State’s] waiver policies. Her knowledge, compassion, and friendly demeanor demonstrates to me that being a case manager is not just a job to her. This is her passion, and her genuine concern shows through at all times.”
  14. “She is very knowledgeable and a great advocate. You can tell how much she cares about the individuals she works with as well as their families. That level of dedication is truly inspiring.”
  15. “My sister has a real life Guardian Angel caring for her! I cannot thank [name of CM] enough, because it all starts from her!”
  16. “She goes above and beyond for all of the individuals she serves. Her follow up on issues is exceptional. She is a true asset to the teams she is on.”
  17. “We really can’t thank you enough. You were charming, patient, collaborative, and extremely knowledgeable and a great teacher. What a combination!” [viii]
  18. “She was there the whole time – helping me and talking to me. She is an angel. You people are lucky to have her.” [ix]
  19. “She is an efficient communicator, expert in resolving and identifying management of our daughter’s illness and a skilled listener.”
  20. “The [case managers organization] ably guided a family member through the health care maze in New York City and kept me updated every step of the way, even though I live in Nebraska. They were knowledgeable, compassionate and also had a sense of humor. Who could ask for more!” [x]
  21. “Their unique blend of professional sensitivity, medical expertise, and personal attentiveness made all the difference in my mother’s end-of-life care. They were literally on the case—reassuring my mother, directing home caregiving, and keeping me sane!”

In addition to comments from patients/clients and families, the following comments from case managers exemplify their feelings about their patients/clients, their case management role, and the rewarding aspects of their case management profession. I’m sure you can all relate to these comments.

  1. “The most enjoyable part of the job is knowing you have made a difference in someone’s life and have provided a good customer experience.” [xi]
  2. “I see [my role as a case manager] as a project manager really. Putting together lots and lots of pieces….. I do love it despite all of the pitfalls. Every day is different. Every client is different. And I think it’s the challenge and meeting those challenges which is my driving point. A lot of people say to me ‘How can you do this work?’ They focus on the negativity, …… but I focus on how I can help that person achieve.” [xii]
  3. “I’m the ‘go-to-girl’, ……. because often that’s the way case management operates. We are problem solvers and hopefully in doing our job we take a lot of the stress and pressure off both the clients and their family. I love my work. I love that every day is different….. I put a lot of work into developing a relationship and trying to find out what the client wants, ……….because sometimes when a client has a disability people stop listening……They tell the client what they should do whereas often the client has quite strong beliefs about what they want as well. And really that’s the important thing.”
  4. “I see my job …. as making myself redundant. [I tell my clients that] if I have done my job well you will no longer need me because the structures have been put in place for you to live independently and for you to be able to manage your own [condition]….. They may need me for a few years to set things up until they gain confidence in and understanding of what they need and how to achieve it. ….. I’ve done a good job if I can walk away and the client’s happy.”
  5. “I very much enjoy seeing the progress of the clients. A lot of these clients have been people that have lost all their independence and have in a very short period of time gone through a very tragic, catastrophic event. [I love] to see them gain their independence and start to interact and participate in community.”
  6. “My favorite part of my job is helping others reach their goals. It’s truly life changing. I work with some great teams, and it’s so rewarding to see everyone come together! [xiii]
  7. “I totally enjoy my job…….I enjoy getting to know my folks, and their families. I enjoy seeing individuals progress from day to day, and celebrating that progress with them. Case Management can be a challenging job, but the rewards definitely outweigh the challenges.”
  8. “My favorite part of my job is being able to work with many different people and learning about their lives and where they want to go. I am so excited when things come together for the individuals I serve.”
  9. “It absolutely makes my day to hear about the accomplishments of the individuals on my caseload and I am so proud to get to have a part in their lives and helping them achieve their goals and dreams!”
  10. “I absolutely love my job, even when under stress; it brings me joy to help those that I serve.”
  11. “Simply helping others is what my journey was about, but the individuals I have worked with have taught me so much more through their strength, goals and desires.”

Additional insights into case management and the lives of case managers can be found in the complimentary e-book, Profiles in Case Management, from the Health Intelligence Network. It provides in-depth interviews from six case managers working in different settings. It outlines their background, skills, choices they made, and their successes. It also touches on trends in case management and some of the challenges that lay ahead. I highly recommend this uplifting article. It’s perfect for Case Management Week (or the week after CM Week or for “CM Month”). I’m sure you will be able to relate to their experiences.

Thank you all again for the wonderful work you do. Keep it up and CONGRATULATIONS!

Comments from Patients/Clients and Families

[i]  1-2

[ii] 3-4

[iii] 5

[iv] 6-7

[v]  8

[vi] 9-10

[vii] 11-16

[viii] 17

[ix] 18-19

[x] 20-21

Comments from Case Managers

[xi] #1

[xii] 2-5

[xiii] 6-11

CCMC 2019


February 28 – March 2

Case Managers come from many different practice settings and have varying job functions. When we come together at an event like the CCMC’s New World Symposium, our diversity leads to amazing discussions and viewpoints about adaptability, effective planning and intervention, and common challenges.

There is no better place to interact face-to-face than at an event that is produced by the most active and prestigious certification organization supporting the practice of case management.

More Details

Artificial Intelligence (AI): Moving Towards the “Bionic Man” (or Woman)

Pat Stricker, RN, MEd

Senior Vice President

In 1950, the medical knowledge doubled every 50 years. By 2020 it will double every 73 days. Based on this, and the fact that other technological advances may increase this even more than currently predicted, how can we expect physicians to keep up-to-date on medical knowledge and evidence-based guidelines for all possible conditions, with variable dependent on their individual patient’s unique situations? Is that reasonable or even possible?

I recently read an article about a study at a large medical center that used Best Practice Alerts to help physicians determine the appropriate next steps in a patient’s care, based on evidence-based guidelines. Physicians do their best to follow the best practices, but it is almost impossible. However, now with the help of artificial intelligence and information technology, specific information based on the patient’s condition can be provided to the physician in real-time at the point of care, as he/she is writing the order.

The study embedded electronic alerts in the EHR system.  At the time the physician submitted the order, the computer system gathered vital statistics about the patient from the EHR and determined if the order met evidence-based guidelines. If it did not, the physician received an alert explaining why it did not meet the guidelines and seeking a reason for overriding it. The physician then had a choice to change the order to meet the guideline or override the guideline and keep the original order, due to specific situations related to the patient’s condition. The study only used 18 alerts out of hundreds of possibilities to reduce the number of pop-ups, so physicians would not become fatigued and begin to ignore them.

The study involved nearly 26,500 patients admitted over 3 years. Results of the study showed that encounters that did not meet the guidelines but were overridden by the physician: increased costs by 7.3%, increased length of stay by 6.2%, increased readmissions rates within 30 days by 14%, and increased complications by 29%. While there may have been good reasons for overriding some of the guidelines, the study did show that using the guidelines would have made an impact on outcomes, as well as costs.

As for the information being provided to the physicians, I’m sure some probably liked it while others may have thought of it as an intrusion into their normal routine. But with the enormous increase in the number of treatment modalities today, it seems like it would be a definite help for medical professionals to have a decision support system, such as this, to help them make decisions.

This made me look into other new innovations being used today or being studied for future use.  While some of these are very recent, others may have occurred in the past few years and I was not aware of them. I hope they are all new to you also. I have included links so you can obtain more detailed information, if desired.


Screening Test

  • Eye Exam for Alzheimer’s: A new retinal scan using polarized light shows promise in being able to identify the risk of developing Alzheimer’s disease by detecting beta amyloid plaques. This could lead to earlier detection and treatment, thereby improving quality of life and overall outcomes. This is also less expensive and less invasive than the current methods of using PET scans and lumbar punctures.


Wearable Devices

  • Skin-like Wearable Monitors: An “electronic skin”, developed of silicone that adheres to the skin like a Band-Aid and can be used on any area of the body, sends data to Smartphones. It is being studied in rehabilitation settings to monitor vital signs, gait, range of motion, and speed or duration of motion. Other studies will be looking at other areas of use for this technology.
  • Parkinson’s Postural Instability: Postural instability and muscle weakness cause about 60% of people with Parkinson’s Disease to fall each year, leading to loss of independence and other more serious complications. The American Parkinson Disease Association (ADPA) funded a grant that developed a small, lightweight, biofeedback belt lined with sensors that transmit real-time mapping of movements to a smartphone application. In turn, the belt makes the patient feel as if the physical therapist is touching them and guiding their  Initial studies showed “noticeable improvement” in performing daily activities and physical therapy exercises at home because patients felt safer and more confident in their movements.
  • Scalp-Cooling Cap to Reduce Chemo-Related Hair Loss: Scalp-cooling caps were approved in 2015 by the FDA for “reducing the frequency and severity of hair loss” in adult patients with solid tumors receiving chemotherapy. (These have been available in Europe for several decades). While the loss of hair may seem like a minor issue to some, given the gravity of the overall cancer diagnosis, however, one in 12 women with breast cancer avoid chemotherapy for fear of hair loss. In initial trials about 50% of the women who used the cap kept some or a large amount of their hair and didn’t have to use a wig. These results mean nearly 800,000 Americans could avoid significant hair loss and it could make women more comfortable in deciding to take chemotherapy, if needed.
  • Oxygen Glasses for COPD: Oxygen glasses offer an alternative to having to wear a nasal cannula. The frame of the glasses conceals small tubes that can be inserted into 1 or both nostrils. The tubes continue down each stem to the back of the head where the tubing is connected to a small oxygen canister that can be hidden under loose clothing or carried in a small pouch. While the tubing can still be seen if viewed closely, it is not very apparent. This gives those who are self-conscious about going out in public, because of their nasal cannula, a “fashionable” alternative that most people won’t even notice. This has the potential of increasing socialization and one’s compliance with oxygen usage.
  • Exoskeletons for Stroke and Spinal Cord Injuries: The FDA has approved several exoskeletons (a rigid external covering for the body providing support and protection) that allow patients who have had a stroke or a spinal cord injury to walk. This is not only a life-changing event for these patients, but eliminates wheelchair complications for them, e.g. digestive problems, heart disease and brittle bones.
  • Vibrating Insoles: Age, diabetes, and nerve damage in the feet dull the sensors that help maintain balance, thereby causing a potential for falls. Foam insoles, with embedded actuators that provide stimulation that feel like pressure or movement, have been developed to mimic the nerves in the feet. Studies showed these insoles significantly  improved their balance.

New Treatment Innovations

  • New drug for Multiple Sclerosis – Most treatments for MS target T cells, a type of white blood cell. A new drug has been developed that targets B cells, another type of white blood cell. The drug is undergoing multiple studies but is showing promise in initial studies in being able to reduce symptoms, slow the progression of MS, and reduce relapses when drugs targeting the T cells are not effective.
  • Immunotherapy Drugs for Cancer: These types of drugs work with the immune system to help fight cancer. They are used with or instead of traditional chemotherapy and have shown great promise. One of them, Keytruda, was used in 5 trials with 149 people who had 15 different types of cancer. Almost 40% saw the tumor shrink or disappear and it lasted for at least 6 months for 78% of the patients.

New Technological Advances

  • Artificial Retinal Implant: A artificial retinal implant that provides limited vision to patients with retinitis pigmentosa, will now soon be available to patients with all types of blindness. This “bionic eye” consists of an implant on the retina and glasses containing a tiny video camera. Truly amazing!
  • Virtual Reality (VR) for Chronic Pain Relief: Studies have shown that VR headsets immerse people in a virtual world, thereby distracting them from their chronic pain. Patients have reported a 24-60% reduction in pain while being engaged in a VR experience. Some even reported pain relief for at least a day after the experience.
  • “Smart Gloves” for Gaming: “Smart gloves” are designed to reduce the monotony of stroke rehabilitation exercises. They allow patients to play more than 45 games designed to target specific goals to improve wrist motion or finger dexterity. The rehab still gets accomplished, but it’s a lot more fun.
  • Artificial Pancreas”:  The artificial pancreas was approved by the FDA in 2016. This device, worn externally, communicates with a sensor in the abdomen to monitor glucose levels and administer appropriate insulin doses via a pump. It has drastically changed the lives of many insulin-dependent diabetics and has been shown to maintain steady glucose levels and has even dropped A1C levels by a half percent. Further work is being done to make it a stand-alone closed-loop artificial pancreas.
  • Earlens Hearing Device: An innovative hearing aid approved by the FDA in 2015 uses a laser light signal and direct stimulation in the eardrum to amplify sound. This has been found to help those who haven’t had success with traditional hearing aids. This innovation is particularly important in light of research that shows that hearing loss may be associated with impaired memory and an increased risk of dementia and Alzheimer’s disease.

(Note: With artificial intelligence, the retinal implant, artificial pancreas, “electronic skin”,  and exoskeleton we are on our way to creating the “Bionic Man” (or woman)!  This is just a little reminder for those of us who remember this TV show from the mid-70s. We thought it was science fiction then, but it is becoming a reality).

It is totally amazing to me how medicine has changed since I started my nursing career. I’m going to show my age here, but at that time we primarily worked in a hospital, home health, or a doctor’s office. Urgent cares, outpatient centers, and call centers had not been developed yet. All documentation was done manually and access to the patient’s record was only available if you were physically in the same room with the record.  It took 2 minutes to take a temperature because the lead thermometer needed to under the tongue (or elsewhere) for at least that long to register. FAX machines were the big technology innovation – making it much faster to get information than using “snail mail” through the Post Office. There were no cell phones, but pagers were being introduced so there was some connection without being physically connected to a land line. Informational content was only available in written material or books. Drug information was contained in a thick PDR (Physician Desk Reference) which was updated once a year. Medical information on lab values, procedures, surgeries, and other guidelines were available in small pocket-size books that were carried in the bulging pockets of lab  coats. I could go on and on, but…………

I know some of you cannot even conceive of what it was like to live in a non-internet, non-computerized world!  I can’t even imagine how we got things accomplished, but it seemed to go well at the time. We had no idea what was coming our way in the next 50 years, just as we have no idea what lies in store for us in the next 50 years. I can’t even imagine. Can you? I am sure it will be totally amazing!!

Embedded Case Management Program Strategies to Advance the Triple Aim and Promote Value-Based Care (Part 2)

Pat Stricker, RN, MEd

Senior Vice President

The use of embedded case managers (ECMs) at the point of care continues to grow each year as the healthcare industry recognizes that they are critical to the development of programs designed to advance the Triple Aim and promote value-based care delivery. Last month’s article, Embedded or Co-located Case Managers:  A Critical Component of Value-Based Care, explained the evolution of embedded case management (ECM) programs, defined the roles and responsibilities of embedded case managers (ECMs), noted the growth of case management positions, discussed the rapid growth of ECM programs, and reviewed program results. This month’s article will focus on the overall goals, objectives, strategies, operational challenges, success factors, and lessons learned.

In 2001, the Institute of Medicine (IOM) released a detailed report, Crossing the Quality Chasm: A New Health System for the 21st Century, examining the chasm that divides what healthcare should be versus what healthcare actually is. The report pointed out that not only was the healthcare system lagging behind in providing ideal care, but that it was not even fundamentally able to reach the ideal. This was a wake-up call to the industry. It meant that in order to achieve improvements in healthcare, monumental changes needed to be made to the entire system.

The report described six Aims for Improvement that needed to be made to the whole healthcare system. These aims specified that healthcare must be:

  • Safe: This must be a main focus and goal of the entire healthcare system. It is more than “do no harm”. It means no one should ever be harmed by healthcare.
  • Effective: Medical science should be used to assure the best available treatment techniques are used and to prevent the overuse/underuse of these techniques.
  • Patient-Centered: The patient’s culture, social background, and needs must be respected. Patients must be encouraged to actively participate in making healthcare decisions.
  • Timely: Care should be prompt. Delays that do not provide information or time to heal should not be tolerated.
  • Efficient: Continuous effort should be focused on reducing all types of waste (equipment, supplies, space, utilization, and time) in order to ultimately reduce costs.
  • Equitable: High-quality care should be available to everyone regardless of race, ethnicity, gender, or income.

These fundamental changes to the entire healthcare system seemed overwhelming, as it meant changes needed to be made to every aspect of healthcare: the patient experience, policies, payments, regulations, accreditation, professional training, procedures, etc., as well as all healthcare environments, e.g. hospitals, clinics, sub-acute and outpatient facilities, health plans, pharmacies, etc. It also required changes to local and national governmental agencies dealing with healthcare. Donald M. Berwick, MD, MPP, former President and CEO of the Institute for Healthcare Improvement (IHI) and one of the Chasm report’s architects said, “No matter where you are, you can look at this list of aims and say that at the level of the system you house, the level you’re responsible for, you can organize improvements around those directions.” He was calling for everyone involved with healthcare to make whatever changes they could at their level to help promote these six improvement aims and to include them, whenever appropriate, in all programs and initiatives.

The IHI continued to work on defining these aims, which led to the development in 2007 of the Triple Aim: a simultaneous pursuit to:

  • To improve the entire patient care experience, as defined by the six improvement aims noted above. It should not be focused on only improving patient satisfaction.
  • To improve the health of populations, which is a wide-spread approach that requires the engagement of partners across the community, not just within the healthcare systems.
  • To reduce per capita (per person) health care costs and allowing organizations to use the resources in other ways. It should not focus entirely on cost reduction, but rather the value received from the money invested.

The IHI noted that the Triple Aim is actually a single aim (improving the entire U.S. healthcare system) with three separate dimensions. While some organizations modify the dimensions, the IHI stresses that this should not be done. Modifications can weaken the overall Triple Aim framework and alter the significance and degree of changes needed.

It took a while for this framework to be understood, but new, innovative care delivery programs slowly began to be developed. In 2007, the Patient-Centered Medical Home Model was endorsed by primary care physician associations and by 2012, forty-seven states had developed programs. This led to the need for case managers who were embedded at the point of care in the clinics, instead of being located remotely in health plans or call centers. By 2017, according to a survey conducted by the Health Intelligence Network (HIN), two-thirds (66.13%) of all respondents said they used ECMs within care sites. Research studies over the years have shown that ECM programs that adopted truly integrated, collaborative care models are very successful. So, let’s look at what makes these programs successful.


Goals and Objectives

The goals of an ECM programs should be long-term, primary outcomes that an organization wants to achieve. A program may start by identifying the Triple Aim as key goals: to improve the entire patient experience, improve the health of populations, and reduce the per capita (per person) healthcare costs. They may then add other more specific organizational goals, e.g. to effectively manage high-risk patients for complications; to improve quality of care and quality of life; to improve patient outcomes; or to foster closer relationships between the physicians and the health plan.

Objectives are then developed to provide actionable, measurable steps that will be taken to meet the goal. They are measured using timelines, budgets, performance measures, and quantifiable resources. Examples include:

  • The patient experience goal should include specific objectives to identify and measure all aspects of care, education, decision-making, treatment modalities, quality, satisfaction, and outcomes for the entire experience.
  • The goal of improving health of populations may go beyond the health system itself and encompass the entire healthcare community, e.g. the involvement of local and national governmental agencies, non-healthcare community organizations, etc. They usually consist of four key objectives that answer “How much of what, will be achieved by whom, by when?
  • The goal of reducing the per capita cost of healthcare needs to include objectives that define the cost reductions, but they should not focus just on cost-savings. They should identify and measure cost reductions, as they relate to the value received from the money invested. What measurable value-based benefits are obtained as a result of the cost reduction? Organizations may be allowed to use the cost savings elsewhere to enhance the overall experience.
  • Other specific program objectives may include:
    • Identifying and improving value-based care initiatives
    • Improving Transitional Care programs
    • Providing more care to more people in real-time
    • Reducing unnecessary utilization of services, e.g. admission/readmission to acute care facilities, length of stay in acute and sub-acute facilities, unneeded treatments and procedures; urgent/emergent care visits; duplication of services
    • Assuring follow-up office visits are obtained within 30 days of hospital discharge
    • Assuring at least 2 office visits/yr. are scheduled and kept for certain chronic conditions
    • Eliminating gaps and fragmentation in care
  • The Six Aims for Improvement (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity) should be considered for inclusion in all goals and objectives, as appropriate.


Clearly-defined Strategies

In order to achieve objectives, clearly-defined strategies (policies or specific action plans) need to be developed. Strategies are determined by analyzing a program’s strengths, weaknesses, opportunities, and threats and then using that information to build appropriate strategies that outline the steps that need to be taken to achieve each objective. Strategies usually answer “how” and “what” will be done and how objectives will be measured. Keep in mind that strategies need to be reviewed frequently because protocols and processes continue to evolve, which means the strategies need to evolve also.

Examples of strategies may include:

  • Using cost-savings in other ways to enhance the overall experience
  • Avoiding complications that lead to admissions/readmissions
  • Controlling disease progression through education and patient engagement
  • Monitoring and managing variances
  • Streamlining processes to improve productivity and workflow efficiency
  • Improving access and use of appropriate services
  • Increasing home visits to assess patient and environment


Operational Challenges

As beneficial as ECM programs are for patients, providers, office staff, health plans and the ECMs themselves, they do present challenges. Setting up an ECM program takes a lot of time, effort, and planning. It is not as easy as just placing a CM in the office. The ECM needs to be totally integrated into the office and work as a collaborative partner and valued member of the team. Yet initially the staff may not “buy-in” to the ECM program and may consider the ECM as an “outsider”. ECMs can also be seen as just another member of the staff and asked to help with office functions when it gets busy. This could interfere with the ECM being able to complete the tasks they are responsible for. To alleviate this, the ECM’s roles and responsibilities need to be clearly defined and discussed with the office staff at the beginning of the implementation. This will allow the ECM to stay focused on CM functions and, in turn, alleviate some of the tasks that the office staff used to perform. Soon the staff will wonder how they ever got along without the ECM.

To create buy-in the office staff needs to be intimately involved in the development of the program including its goals, objectives, strategies, expected outcomes, operational policies and procedures, patient engagement strategies, and reporting. In order to do this, relationships need to be developed with the office staffs in management, administration, nursing, customer service, utilization management, finance, and provider networking to learn and understand their key activities and operational procedures. The same type of partnerships also need to be made in the surrounding medical community that work closely with the office, e.g. home health, sub-acute facilities, rehabs, nursing homes, hospitals, pharmacies and other community agencies. All of these things take time and effort, but it helps ensure cooperation and buy-in from the office staff.

embedded case managementThis chart from the Health Intelligence Network’s 2017 Healthcare Benchmarks report shows the ECM challenges reported by 78 organizations in the HIN survey. Another challenge not on this list, but often discussed, is the difficulty in finding an available office for the ECM. Another challenge for the ECM is the difficulty in having to learn multiple computer platforms. Providers and office staff may also have initial concerns about having to redesign and standardize their workflows, but once the program is operational they realize the standardization helped to make the processes much easier and less chaotic.


Success Factors and Lessons Learned

Over the years, as ECM programs have evolved, we have learned what works and what doesn’t.

These are some of the success factors and lessons learned from organizations who have implemented ECM programs.

A Geisinger Health System presentation entitled Embedded Case Manager given at a Medical Home Summit provides a good overview of their program including the rationale for their program, goals and objectives, tips on operational needs, CM functions, key attributes of choosing the right ECM, a detailed discussion of their 6-8 week orientation plan, and a discussion of their training and preceptor program.

Choosing the right case manager is a critical component of any program, so let’s look at some of their suggestions.

  • A candidate for an ECM position must be a good fit for the office, so the providers need to be involved in the selection process.
  • Prior CM experience is not a requirement, but experience in an office practice, home health or community nursing is helpful. The ideal ECM should:
  • Be autonomous, self-motivated, personable yet self-confident, supportive, empowering, highly organized, an independent thinker, and a passionate patient advocate
  • Be able to handle complex issues, drive outcomes; shift focus easily, multi-task yet still remain on task; work well with others
  • Possess these essential skills: interviewing, assessment, communication, active listening; problem solving, relationship-building, critical thinking, patient engagement, time-management, negotiating, and conflict resolution.
  • Feel comfortable reaching out beyond the health system and working with other outpatient and community organizations that can help the patient and/or family.

  • Geisinger also found that it is important to maintain ongoing communication with the embedded CM. Monthly meetings should be conducted with each ECM to: review cases and documentation; evaluate the program’s goal and objectives; discuss provider and staff interactions and relationships; discuss problems and opportunities for improvement; discuss management of gaps in care; review performance, productivity, and caseloads; and review programs outcomes, e.g. reduced readmissions, utilization, patient engagement, and patient follow-up visits.

Designing the Role of the Embedded Care Manager, is an article that discusses the framework for designing an ECM program and implementing ECMs into a physician practice. The authors looked at four early adapter organizations to determine the key elements of each program and to identify

Lessons Learned:

  • Four critical components for implementation are: identifying physician champions; redesigning patient workflows; developing multi-disciplinary care teams that work to engage patients in their plans of care; and using EHRs that have robust data-reporting capabilities.
  • A well-executed implementation plan is essential.
  • The staff should be allowed to participate in the redesign of their responsibilities and workflows.
  • The ECM’s roles and responsibilities need to be clearly communicated to the team.
  • The ECM should be the central point of contact, thereby eliminating redundancy and confusion.
  • Most importantly, the role of the ECM needs to be communicated to the patients. They need to understand that they are not only a care manager, but a patient advocate and another resource for the patients and their families.

The article also discussed Success Factors:

  • Care coordination takes time, effort, and financial resources, but is worth it because of the support it provides to physicians, patients, and families.
  • Training and processes need to be redesigned with emphasis on communication, coordination, collaboration, and accountability.
  • Continuous improvement should be an ongoing initiative.
  • Program strategies, policies and protocols need to be reviewed at least once a year to assure they still conform to the program goals and objectives. Protocols and processes will continue to evolve, so strategies need to change also.
  • Specific issues and gaps in care should be analyzed and reviewed to determine if changes need to be made to the program.
  • An organizational change of this magnitude requires a cultural transformation.

The most important success factor is the Embedded Case Manager! 

For those who want more detailed information about Embedded Case Management, the following articles and resources also provide valuable information:

The healthcare industry has made great strides in attempting to transform itself since the introduction in 2001 of Crossing the Quality Chasm: A New Health System for the 21st Century and the introduction of the first pilot Embedded Case Management program in 2007. The number of ECM programs have grown and will continue to do so, as the industry continues to move from volume-based reimbursement to value-based care. This industry-wide organizational change has created a cultural transformation that is predicted to lead to a more patient-centered team approach to care management. It seems that organizations and individuals have begun to embrace these changes, since the results and outcomes have been very positive. However the changes are not finished yet, so we need to continue to monitor the healthcare transformation. It is reassuring to know that case managers are in the midst of this industry-wide transformation, because case managers are capable of doing anything and they do it well.

Healthcare Solutions, Behavioral Health, and Case Managers

Deborah Keller, RN, BSN, CMCN, CPHQ

Chief Operating Officer

As a healthcare solutions vendor, we are committed to leveraging our unique place in the healthcare industry to gather and share the vast expertise we are so privileged to have within our client base.  With that goal, I am beginning a series of articles focused on how medical case managers can support their patients with behavioral health disorders or conditions.  In researching this topic, I have recently had the wonderful opportunity to interview several behavioral health experts across the country.  I have learned so much through these interviews that I can’t possibly include it all the material in my upcoming articles.  So, without giving away too much of the content of the articles, I would like to share some of what I have learned along the way via a coordinating series of “Thought” blogs on this topic.

Thought One:  With over sixty percent of psychiatrists in the United States being aged 55 or older and psychiatric residencies routinely unfilled, we are facing a shortage of services unprecedented in any other healthcare specialty in history.    This shortage is occurring at a time when we are experiencing a suicide crisis.  Despite the efforts to address the shortage of psychiatrists, the trend is expected to continue a path of growing disparity of a 3:1 ratio by 2026.  While case managers certainly cannot directly impact the shortage of psychiatrists, by increasing our knowledge on the treatment pathways of prevalent behavioral health conditions and better understanding our support role, we can positively impact our behavioral health patients and even help save lives, one at a time.

Co-Located or Embedded Case Management Is a Critical Component of Value-Based Care

Pat Stricker, RN, MEd

Senior Vice President

The case management profession has changed dramatically in the past 25 years. In the late 1990s case managers primarily worked in acute and post-acute facilities, health plans, medical management organizations, and workers’ compensation companies. That began to change in the early part of the 21st century with major changes that occurred in the healthcare industry. More emphasis was being placed on finding ways to deliver more efficient, quality care that was also more cost-effective. Healthcare was moving from a fee-for-service payment system that was based on the quantity and volume of services to a value-based system that was based on the quality and value provided by those services. New care delivery models and healthcare reforms, brought about by the Patient Protection and Affordable Care Act, meant that new innovative ways of delivering care needed to be developed. This certainly helped to spotlight case managers and the value they could bring to these programs.


The Case Management Society of America played a big part in promoting the practice of case management at the highest levels of government and the healthcare industry. Our leadership has effectively worked with local and national government agencies for years to educate them about the importance and value of case managers. This has resulted in an increased recognition and appreciation for our role and, in turn, has led to newly developed programs requiring case managers. These care coordination, transition of care, and case management programs help to assure that the value-based Triple Aim for optimizing healthcare system performance (better care, better health, and lower cost) is achieved.


Case managers are seen as a critical component in these new care delivery systems. They are recognized as valued care team members who are able to provide clinical expertise and outcomes, care planning, quality care, and cost-effective outcomes while helping educate and navigate patients and their families through the increasingly more complex healthcare system. The number and types of roles and responsibilities of the case managers have been significantly enlarged, making them sought after in other care delivery areas, such as: primary care provider (PCP) offices, clinics, outpatient facilities, care organizations, hospital admissions, emergency departments (EDs), long-term care facilities, nursing homes, community clinics, employer work sites, and government programs like the Indian Health Services and the Veterans’ Administration. This has caused the need for a significant increase in the number of CMs in these non-traditional areas.

Defining Embedded vs. Co-located Case Management 

In 2007 the major primary care physician associations developed and endorsed the Patient-Centered Medical Home care delivery model that is focused on providing care that is comprehensive, patient-centered, coordinated, accessible, safe, and of the highest quality. By 2012, forty-seven states had developed medical home programs. This led to a significant need for “co-located” or “embedded” case managers in physicians’ offices and clinics. The word “co-locate” is defined as: “to locate 2 or more things together; to place close together to share common facilities”. Co-locating case managers in an office or clinic provides the ability for better communication and coordination, however it does not, in and of itself, assure an atmosphere of integration and collaboration that elicits the concept of working as a member of an integrated, collaborative team in order to share knowledge, principles, and care plans to help patients meet their goals. The term “embedded” is defined as: “to make something an integral part of; to attach (someone) to a group for the purpose of advising, training, or treating its members”. This definition goes further to describe the embedded CM concept and the CM’s close relationship or attachment to the group. “Embedded” more adequately describes the case manager’s role in becoming a truly integrated member of the group and a collaborative partner. Research studies over the years have shown that programs that have adopted truly integrated, collaborative care are significantly more successful than those who merely “co-locate” their case managers.

Statistics on Embedded or Co-located Case Managers

The rise in these programs has led to an increased need for additional case managers (CMs), especially in non-traditional areas like PCP offices, EDs, hospital admission departments, etc.  Surveys conducted between 2012 and 2017 by the Healthcare Intelligence Network substantiated this embedded movement into non-traditional areas.

  • The number of CMs in organizations continues to grow – from 88% in 2013 to 94% in 2017.
  • In 2013, respondents said they had CMs embedded or co-located in 54% of their care sites. (Care sites include some of the other areas noted above).
  • By 2017, two-thirds (66.13%) of all respondents said they embed or co-locate CMs within care sites. Hospitals had the highest number of embedded or co-located CMs (77.78%), while health plans reported 50%.
  • In 2011, only 14% of CMs were embedded or co-located in PCP practices. That number increased to 5% in the 2017 survey.
  • The 2017 survey also found that the top 3 sites for all embedded or co-located CMs were EDs and PCP offices (47.5% each), and hospital admission departments (30%).
    • Hospitals reported more embedded CM in the EDs (85.71%), but fewer in PCP offices (35.71%) and hospital admission departments (28.57%).
    • Health plans reported 4 sites that were equally distributed at 25% each: PCP offices, hospital admissions, a mixture of PCP office/home/hospital/etc., and other.
  • In addition, 1% of respondents in the 2017 survey said they plan to add to or implement embedded or co-located programs within 12 months. The greatest interest was shown by health plans (75%), while only 25% of the hospitals said they had such plans.

Embedded CM Roles and Responsibilities

The goals of embedded case management programs are to effectively manage all aspects of care for high-risk, high-cost, complex patients, while also working to reduce hospitalizations and unnecessary costs, assure patient satisfaction, and improve the patient’s quality of life. This will help achieve the value-based Triple Aim: improving the patient’s experience of care (quality and satisfaction), improving the health of populations, and reducing the cost of healthcare.


Programs tend to focus on specific objectives, such as:

  • Assuring follow-up office visits are obtained within 30 days of hospital discharge
  • Assuring at least two office visits a year are scheduled and kept for certain chronic conditions
  • Reducing the number of hospitalizations by avoiding complications


The embedded CMs are not only located in the office, but they need to be closely integrated into the care team as an integral part of the collaborative team. This integration is an essential and critical part of the orientation process for both the CM and the office team members. The CM cannot, and should not, be counted on to be another member of the staff when the office is busy. The CM must focus on her/his roles and responsibilities in order to be effective.


The roles of the embedded CM are similar to other CMs working in hospitals, health plans, medical management organizations, etc. They are responsible for conducting in-depth assessments; developing care plans; assisting with medication compliance and adherence; educating patients and family members; helping patients manage their goals and plan of care; monitoring patient outcomes; coordinating referrals; identifying gaps in care by reviewing claims, prescriptions, and lab results; managing admissions, discharges, and transitions of care; managing post-discharge follow-up calls and visits; addressing safety and quality issues; monitoring variances in care; and conducting patient care conferences with providers and other members of the collaborative team.


Embedded CMs have the unique opportunity to manage a patient through the entire continuum of care, rather than just handling recurring episodes of care. This longitudinal management and ongoing partnership with the patient and family allows the CM to get intensely involved to help empower patients to manage their own healthcare.


Program Results

A review of embedded CM programs has shown that many have been very successful:

  • A 2010 Aetna embedded CM program resulted in a 43% reduction in the number of acute-care days, exclusive of denials. This was a 12% increase over the 31% they achieved in 2009 without the embedded program.
  • Aetna’s Provider Collaboration Program conducted at 2 sites demonstrated reductions in: acute admissions (-30% and -44%), acute days (-33% and -50%), sub-acute admits (-14%), sub-acute days (-15%) and readmit rates (-41% and -55%). ED rates increased by almost 12%, but this was a result of proactive care to prevent admissions.
  • Another Aetna study involving 3 provider groups with Medicare Advantage patients compared acute admissions per 1000 against those of the Centers for Medicare and Medicaid Services (CMS). The 3 groups demonstrated reductions of -46%, -48%, and -63% compared to CMS.
  • An AmeriHealth study, using informatics and embedded CMs, demonstrated a 17% reduction in hospital admissions and a 37% drop in inpatient lengths of stay.
  • A Geisinger Health System study, using embedded CMs in a PCMH model resulted in a 53% reduction in avoidable hospital readmissions, a 25% reductions in acute hospitalizations, and a 23% reductions in length of stay.
  • A Sentara Healthcare System study demonstrated:
    • 17% reductions in ED visits
    • 48% reductions in all-cause inpatient admissions
    • 21% reductions in all-cause readmissions
    • 17% reductions in total cost of care
    • Nearly double the number of 7-day follow-ups (patients followed by a CM had a 98% rate, while the average rate was 49.5%)


In addition to the positive statistical results achieved in the studies, the health plan programs that provided embedded CMs to the PCP offices also received very positive feedback from the participating physicians. The physicians felt the programs saved them and their office staff time by having the CM perform tasks that the office staff previously didn’t have the expertise or time to perform. They felt confident that follow-up tasks and recommendations would be completed by the CM and looked forward to updates from the CM on their patients’ progress. This relationship with the CM also fostered a closer relationship between the physician and the health plan, allowing both of them to meet their mutual goals. These types of programs changed the way processes were done and improved workflow and efficiency, so value-based care could be more easily achieved.


Embedded case management programs continue to grow each year. More and more innovations are being used to make these programs even more effective. This is a definite plus for the case management profession and for the healthcare industry as a whole. These programs fit perfectly into the evolution of moving the volume-based reimbursement system to a value-based system because it advances the Triple Aim of improving the patient’s care experience (quality and satisfaction), improving population health management strategies, and reducing the overall cost of healthcare.

Congratulations to case managers for being a critical component of value-based care delivery!