JPS Health Network’s outpatient case management team operates several programs. Its two largest programs focus on patients with a COVID-19 diagnosis (whether discharged from an inpatient stay or diagnosed without admission) or with a chronic disease. The team includes RN case managers, social workers, and case management coordinators, and it reports through clinical leadership. The outpatient case managers collaborate with inpatient case managers to ensure hospitalized patients are aware of optional post-discharge support, which can include symptom monitoring, care coordination, patient education, and much more. By identifying and resolving outpatient needs, the team helps patients avoid readmissions and improves the health of the community.
• Understand how monitoring COVID-19 and chronic disease patients through outpatient case management prevents readmissions
• Examine the typical duties, case load, average length of stay, and patient contact cadence for an outpatient case management program
• Assess how collaboration of clinical and revenue cycle staff supports case management goals