The Centers for Medicare and Medicaid and the Agency for Healthcare Research and Quality (AHRQ) created a tool to report such patient experiences. Patients can visit CMS’ website at, to compare Medicare programs and hospital providers, Rosenberg said.

He added that CAHPS involves a 27-item questionnaire by mail or phone. The survey is administered several weeks after an aging patient is discharged from the hospital. There must be staff communication, response and medical compliance with federal and state regulations in order to carry out the survey project.

CAHPS is tied to good marketing and Medicare compliance, Rosenberg said. And there is a 2 percent penalty for facilities that do not report patient experience through the surveys. Visitors to the Medicare website can check out senior long-term care facilities, medical facilities and home-based community care sites by zipcode.

Under CMS in the year 2015, Rush medical center will spend $815 million to improve care and patient satisfaction. This will be taken from what Medicare would pay on these patients, he said.

“Social workers can have impact,” Rosenberg said. “Re-direction [translates into a] savings in Medicare.

“[There are many] new emerging and untested approaches. [They involve the] AHRQ and PCMH core attributes. [Care is] patient-centered, comprehensive [and] coordinated. [The result for the patient is] superb access to care.

“[We] must have social insurance that considers the whole person in the context of the person’s larger environment. Social work [is] an obvious fit. [He or she is the] care coordinator of behavioral health, self-management and capitation.”

The physicians, nurses and other practitioners involved are paid per member per month for senior care, he said. They are also paid per member per year as well as per month to provide pediatric care.

“[The concept keeps an] ACOs core principles,” Rosenberg said. “[It is all based on] patient-centered primary care, pay reform and [the use of] care coordinators. [This is] different from HMOs. [There is] no patient lock-in. ACOs have to work to keep their patients from leaving.”

He added that the Medicare Shared Savings and Program (MSSP) rewards them for lowering costs while delivering care.

“[The] social work [model] fits exactly with PCMHs,” Rosenberg said. “Other payors [can be used.] [This is an] underexplored option. [There is] current interest in transitional care of care coordination. [The medical care teams will] need utilization review data. Insurers want to see that interventions decrease expenses.”

Robyn Golden, MSW, LCSW, director of health and aging at Rush University Medical Center and a panelist, agreed, stating that the different tasks performed by social workers are transferrable skills needed to round out a transition of care effort for aging patients.

“[The] physical wrap-around [continuum of medical care] and PCMH (Patient-Centered Medical Homes) encourage healthy homes,” Golden said. “[The] role for social workers [is] in [the] augmentation [of] the patient’s primary and specialty care encounter. [They] address gaps, provide compensatory help and assess patients’ psychological health. [They are also] educational providers.

“This resource is controlled to PCMH success. [This leads to] true improvement [of] income [and] health. [The] team [includes a] master of social work [degree, training and experience]. [This is] wraparound medical care addressed by non-medical needs. [It] increases premium care clinician awareness and proactivity. [It] follows the principle of patient empowerment and self- determination.”

She said social workers use motivational interviewing strategies, assessment, [medical] plans of care and reasons for referral to start and shape PCMHs and ACOs. They take into account patient safety, identified values and preferences as the “social determinants of health.”

For Rush medical center in particular, the outcomes of its transitional care model are that social workers proved themselves to be indispensable because they possessed and fostered a profound understanding of medical assistance language at an appropriate educational and training level, Golden said.

This was the result of using better-educated and trained social work discharge planners in 2007 and implementing an Avoidable Readmissions Penalty Charge (ARPC) in 2011.

“[It is about] building interventions and biophysical assets around the social dimension,” she said. “[The master’s degree program at colleges and universities provides] preparatory [training] for social workers.”

Golden explained that the social workers coordinate medical teams of care on a pre-discharge basis with two days of post-discharge activity and 30 days of follow-up. “We talk to patients and caregivers and work with the community,” she said.

CPTs allow for reimbursement are particularly meaningful for Rush’s PCMHs because social workers, otherwise in a traditional medical arrangement and setting, would not be allowed to bill under federal law as this would the preserve of hospitals and their physicians.

To enable medical care service category definition and billing, Golden said two new CPT codes have been introduced by CMS and the AMA: for care transitions and patients. They are Care Transitions CPT codes. Two new codes have also been developed for modes of medical complexity or high health complications among aging patients.

“What [about] the future and [new] codes?” she said. “The ACA (Affordable Care Act) [will influence] complex chronic care and coordination services. [You] can charge one. The Rush Generations program [offer patients a comprehensive continuum of geriatric care for seniors].”

The Rush Generations program is a comprehensive program of a continuum of senior care created by the medical center to offer senior affinity, cross-referenced membership, an identified payor mix and overhead and operating costs.

“What’s next for social work?,” Golden said. “[The field contains the] social determinants of health. [It connects medical] care [with] social work. It [connects] competencies to social determinants of health. Professionals need to do [a] better job of defining [the title].

“[In the future, there will be] advocacy. We need to speak for ourselves. [There will be improved] payment models, [more] CPT codes and [models of care] for chronic care [illness].”

Read This Story From the Beginning: Part One

This article was originally published March 10, 2014 on the website of, one of seven websites that comprise The Pharm Psych Network, a medical communications and education company.