CHAPcast by Community Health Accreditation Partner
CHAPcast: Your Trusted Partner on the Go
For over 60 years, CHAP has been leading the way in home and community-based care, and now CHAPcast is leveling up! With a dynamic new format, co-hosts Jennifer Kennedy and Kim Skehan bring their expertise, passion, and a touch of personality to every episode.
Get ready for deeper dives into the issues that matter—breaking down policy updates, exploring cutting-edge trends, and sharing practical tools to help you thrive. Fresh perspectives and actionable insights you can use right away.
Whether on a commute, in the office, or just catching a moment to yourself, CHAPcast is here to keep you informed, inspired, and ahead of the curve.
The views expressed do not imply an endorsement by CHAP or any entity they represent. Opinions expressed by CHAP employees are their own and may not necessarily reflect the organization's views.
CHAPcast by Community Health Accreditation Partner
Case Management: The Backbone of Home Health and Hospice
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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Greetings and salutations. I'm Jennifer Kennedy, the lead for quality and compliance at CHAP, and welcome to CHAPcast. So what we're going to talk about today is the importance and role of case management in both home health and hospice, and this whole concept of good case or care management is really important for each and every patient. You know, it can make the experience great or it can make the experience meh, and it's also really important to coordinate with the rest of the either the home health team or the hospice team for each and every patient. I am so glad to be talking about this topic with my colleague and good friend, kim Skehan. What do you think, kim? Are we going to tear it up with case management? Are we going to tear it up with case management?
Speaker 2:Absolutely, and you know I have said this for many years.
Speaker 2:Case management is a topic near and dear to my heart from the time I was a clinician in the field.
Speaker 2:Through manager and leadership and certainly with survey, we know that effective case management is vital but often underutilized, a component that really supports optimal patient management.
Speaker 2:And, from a survey perspective, many of our survey findings, as you know, Jennifer, at the standard level or condition level and even sometimes immediate jeopardy, are related to care planning, assessment, follow-up and updates and coordination of care, where aspects of the patient's care were not addressed or followed up or reported and therefore care delivery is impacted and then at times results in actual or potential negative outcomes.
Speaker 2:So it's really important that home health agencies and hospices understand case management. We know that both the state operations manuals for home health and hospice do discuss coordination of care, the importance of the RN or, in home health, therapist in coordinating and leading care and ensuring that the patient's needs are being met. All aspects, not just the wound that the nurse is going in to see or, you know, the exercises that are being provided by the therapist, that we really have to make sure that those needs are being met. And hospice and I think I'll tag over to you when we talk about hospice, you know, has it easier because we have an embedded IDG requirement. But at this point, with care delivery, most home health agencies should also have a component of interdisciplinary team coordination.
Speaker 1:You know, kim, I think you're right. I think, when I think about case management and you know the time that I spent in the field and when I've sort of moved on and have been talking to providers out there that concept of case management and getting it right it's hard Because that's, you know, case management's not a skill you're necessarily going to learn. Either you know social work school or nursing school, and when you come to an organization that you're going to work for, then it's really a you know onus on the organization for them to teach you what good case management looks like for them. But you know, I feel like case management well, really home-based care overall is like a gap when you're talking about the whole schooling piece of different disciplines and in terms of home health and hospice, it's really really important. If we're going to say we're an organization that does patient-centered care, then we have to case manage all of that care so it meets the what matters for that patient.
Speaker 2:Absolutely and to your point, case management is a learned skill and not every visit clinician can be a case manager. So, as an organization, really understanding how your operation wants to optimize, you know the skills of a case manager, of an RN or therapist in home health as a case manager, to really whether it's a case manager who leads, you know several patients and manages the care, or if it is the primary care clinician in the home. Like I said, in home health they identify the clinical manager with those responsibilities, but the reality is that it is the clinician in the field who is observing, coordinating, identifying any additional assessment and care plan needs. And also, to your point, if you have a clinician who's new to home health or hospice community-based care, that takes time to be able to understand. Not just the aspects of what I need to do for a visit, what I need to do for regulation, right, for documentation.
Speaker 2:Case management is a next level skill that you can't. It really isn't something that can be, you know, given or instructed to a new staff member on day, you know, day five or day 10. Right, right, you know day five or day 10, right, right, really have to look longer, you know, into the clinicians orientation and training. You know three months, six months and revisit it.
Speaker 1:Yeah, you know, and I don't know if many organizations spend the time that they need to in their onboarding and that first I'll say year that they bring somebody on and really hand-holding them through. Okay, this is what it means to be a case manager and this is the framework we use and this is why we do it and all of those things, and it's probably. If someone out there listening has 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 for many providers, absolutely so. When we talk about the importance of case management, kim, why is this so important? To get this particular, as you say, learn skill down.
Speaker 2:Well, remember that home health or hospice or any care setting the goal is holistic care and ensuring that all patient needs are being met care such as medication management, psychosocial needs, maybe some you know mobility needs or mentation that needs that would be benefited by referring to another discipline or not knowing what the other disciplines are.
Speaker 2:The goals of care for the other disciplines are. We also have seen situations where there are patients who are behavioral health patients primarily, who their medical needs may not be met because the focus is on behavioral health. But we also see it vice versa, right, those patients who we have the medical needs but they're again psychosocial or the mental health needs are not effectively being cared for or addressed as well as the care coordination and care transitions. You know it's so important to make sure that there is evidence of that coordinating care, not just internally but with any external resources that are also supporting the patient, including the physicians. And, most importantly, it's really for the potential for improved outcomes for the patient. And again, looking at what matters to the patient when we look at age-friendly care at home and knowing who's on. I call it knowing who's on first right.
Speaker 1:Who's?
Speaker 2:on first, knowing and coordinating each team member's goals, as well as the patient's goals or family goals, and not just the specific discipline intervention, and connecting those dots and documenting.
Speaker 1:Yeah, document, document, document, for sure.
Speaker 1:You know, and CMS has said for years, a lot of years, that you know one of their target areas was, or transitions in care, where they feel like that point in a patient's health care is a potentiality for low quality to happen. So when we fast forward then and look at case management, if we're doing good case management, then you're supporting them to pick up the thread from one provider type to your provider type so that there isn't a gap, essentially, and a potentiality for drop in quality. So, yes, it's the right thing to do, but also from a compliance standpoint. Cms has been watching this for a lot of years and it continues to be an item of watching, so I don't know if we're, as a healthcare continuum, quite getting it right.
Speaker 2:No, I would agree with that for sure.
Speaker 1:And when you're talking about key considerations for those primary nurses and therapists when managing patients and families. What are you thinking when you're talking about key considerations?
Speaker 2:That's a great question. So when it comes to case management and care management right of the patient, we are looking at what I'm really talking about, looking beyond, just again, the interventions on the care plan, looking more broadly at the needs of the patient and coordinating that care and being aware of the services that are being provided in that home to support the patient. Many times I can tell you, being in the field and with agencies, when the clinicians in the home are not aware of what other disciplines are in the home and what those goals of care are. So that's happened more frequently than we'd like to see. And again, also, those times when there are, you know the dots aren't being connected in terms of potentially negative outcomes or areas that need additional follow-up. So that assessment, the care planning, the facilitation of care and services, coordination and evaluation and advocacy for the patient is extremely important and that good case management supports patient and family, effective self-management when appropriate and continuity of care that contributes to a good patient experience.
Speaker 1:So, you know, I think it's fair to say that sort of the nuts and bolts of case management in home health and hospice kind of remain the same, and they have over the years. But there are subtle changes because of course healthcare has been changing, you know. And when we think about things like AI and how that's going to impact case management, what are your thoughts about that?
Speaker 2:I think that from a documentation standpoint, there actually are benefits, right to be able to have these integrated EMR, you know systems where we can easily view, or more certainly more easily than a long time ago, in terms of knowing what the care is that's being provided, what the goals are, what the care plans are.
Speaker 2:We have integrated care plans AI you know it's early in the game but certainly I can say that from what I've seen and what we've seen you know here at CHAP is there is absolute progress, you know, and opportunity for organizations to be able to use AI to be able to capture across, you know, across the patient's care, what you know, any areas that may fall out.
Speaker 2:And also, I think it can also assist with some of the oversight, because one of the key components is we're relying on the clinicians in the field to assess, identify, report, observe and document and communicate. And we want to make sure that there is that oversight component within the organization, whether it's the clinical manager or quality someone is looking to, or IDG, in the case of hospice right, is looking to, or IDG, in the case of hospice right, someone is looking to make sure that the dots are being connected, not just at the time of I'll use hospice as an example IDG, you know, every 15 days, minimally every 15 days, but what I call and I'll give a shout out to Dave Matthews, but what I call and I'll give a shout out to Dave Matthews, the space between which is the space between those visits, right, that in that documentation, is where, on hindsight, right when you're reviewing, you can see where there were opportunities, you know, for the team to be able to, or the case manager to be able to affect, to address some potential issues.
Speaker 1:So do we agree that good case management equals better outcomes?
Speaker 2:Absolutely yes. I do believe that I've seen that not just from a patient standpoint. I've seen that not just from a patient standpoint but a patient health and safety, but also from survey. Because again, when we look at survey, negative findings, again typically at the condition level or potentially IJ, immediate jeopardy most of the time it evolves around comprehensive assessment, care planning, updates and meeting the patient's needs.
Speaker 1:Exactly, and I think. Just another item to throw in here is patient acuity. If there's a higher patient acuity, it's going to take more intensive care, management or case management to ensure you know the patient has everything that they need and all those threads are under control. And I, you know, I think, or I hope, that providers out there do adjust productivity for acuity, because there's a lot riding on it, like you say you know, of course we've's a lot riding on it. Like you say you know, of course we've got patient outcomes riding on it. We have larger things like survey riding on it. Even audits potentiality with the documentation, outcomes of an audit can ride on. Good case management as well. Yep, absolutely so. When we think about asking our listing population out there to step up to the plate and fairly evaluate, you know, the case management practices of their staff, what are some things that they could be asking or looking at?
Speaker 2:Again, an organization. The goal is really to adopt an interdisciplinary care management model that reinforces care coordination and managing the patient, not just making visits. And even in hospice, where we have a prescripted or designated IDG, there still is opportunity for the team to be able to, you know, come together and really map out, identify the patient care needs all of them and ensure that they're meeting those needs or coordinating the need to meet those needs. But in looking for an organization determining your processes to ensure effective case management in the field, 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 to give social workers a shout out because they have case management in their realm, they have a down pat and they understand.
Speaker 2:So really, clinicians, home health and hospice nurses and therapists can learn from their colleague, their social work colleagues and therapists in general do a nice job with therapy only and communicating with each other. It's identifying those other care needs, potential nursing, et cetera. And again, just remembering that LPNs, as much as they are wonderful and a wonderful, you know, aspect to the team, they are not, by scope of practice, case managers. So making sure that if they are making those visits, that there is that you know the communication and the coordination to the RN as well. So, looking at who is performing case management, who do you expect to perform case management in your organization? And if it's every RN who is, you know, managing their caseload, then you need to make sure that they have the skills and the resources to be able to understand all of the aspects of case management you know, and what that reporting, what that looks like to manage the needs of the patient, what your infrastructure is for interdisciplinary team or IDG and for oversight.
Speaker 1:Yeah, I couldn't agree with you more. And I again, it circles back when you say all these things to did the organization first of all, if they're bringing somebody in, assess that person's case management skills right and, additionally, teach them what they, that they, that organization feels case management encompasses, and supporting them. You know case management is not easy, as you know. You've done it, I've done it. You know, depending on what your caseload looks like, it can be really difficult and time consuming.
Speaker 2:And you know what.
Speaker 2:You bring up a great point in addition to productivity, especially for those that are case managers versus visit clinicians cas, you know, the all of the aspects of, of the patients that they have assigned to them and another.
Speaker 2:I just want to say also that this is there are many resources that are in place to that are available to be able to provide case management skills or skills of the home health or hospice clinician, one in particular, but there are many, but one in particular I do want to note is Tina Morelli's books, her handbooks, because and I will, I'm shouting out to those particular resources because many years ago and still today, you know, they have been used for clinicians in training, you know, for case management and for care planning and assessment. I've used them in the field, I've used them as a clinical instructor, I've used them, you know, certainly as a manager. But again, there are other resources as well, but you really you don't have to start from zero, right, there are resources. And again, I'm giving a little. The reason I also mentioned Tina is because I know that you also have authored, co-authored, one of her, one of her, the hospice book, correct?
Speaker 1:Yeah, absolutely. You know it's an honor to have worked on two books with Tina. She's a legend, honestly, but you know she gets it and she's able to sort of translate what case management should look like in her red book and her hospice book as well, for sure.
Speaker 2:And again there are other resources, you know that are available but I would highly encourage agencies to identify resources for training, for oversight, you know, and for guidance. Identified the basics right of home health or hospice care and then mastering the skills of case management, looking at what I call next level case management and that's really evaluating disease management and opportunities for, you know, prevention of, you know, either managing disease or prevention of exacerbation of disease such as heart failure, copd, diabetes, wounds. I know that here at CHAP we have, through our Center for Excellence, we have disease program certification that you know many organizations are finding are helping with framing out. If you will, the, you know, the extension of looking beyond what I call the blinders of you know, the intervent, the task at hand. So, looking beyond, you know the wound care or you know, whatever that specific task is, that the clinician is going into the home. They really are looking holistically at the patient.
Speaker 1:Absolutely, and those programs are a great framework for organizations and their staff to follow in specific disease pathways. So, kim, as we wrap up, what are some things that you would like our listeners to take away today? What?
Speaker 2:are some things that you would like our listeners to take away today. Well, I think what we have been saying is that case management, or care management by home health and hospice clinicians RNs, and then RNs and therapists for home health are, you know, is vital. It's a vital aspect of care to be able to have someone connect the dots. If you know is vital, it's a vital aspect of care to be able to have someone connect the dots. If you will make sure that assessment is holistic and that all of the patient needs are being identified and addressed, whether they're being addressed directly through the agency or they're coordinated through another resource. That all needs to be documented, you know very well. So communication, coordination and documentation based on those assessments and care planning of all team members is really vital, and you know, in doing this and making sure that these processes are in place and your staff are trained and skilled, the ultimate result is improved outcomes and that the goal is to minimize patient care issues and potential survey findings as well.
Speaker 1:Exactly Great example where compliance meets quality once again.
Speaker 2:So I wouldn't mind Somehow that's us that is.
Speaker 1:It's the handshake right. There you go.
Speaker 1:One hug Well it's been great to talk to you about this topic, kim. I know you and I could probably talk all day about case management. I would like our listeners to share this episode, as you feel you need to, with the rest of your organization and explore some of the resources or links that we have with our podcast notes and check out our Center for Excellence to see if there are any educational offerings that we have that might enhance your staff's journey to providing great case management. So, in closing, thanks, kim again for teaming up with me. It's always a pleasure for us to talk, you know, on podcast or off podcast. It's always great to spend time with you Absolutely. And thanks to all of you out there in podcast land for taking time out of your day to plug in to our episode about case management From Kim, me and the entire CHAP staff. Keep your quality needle moving forward, stay safe and well, and thanks for all you do. Thank you.
