✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on July 22, 2025.
Value-based care (which includes HRRP and VBP) is a healthcare delivery model that ties provider payments to quality of care. It rewards providers for efficiency and effectiveness. Unlike the traditional fee-for-service approach, where providers are paid based on the volume of services delivered, value-based care focuses on patient outcomes and the value of care delivered.
As mentioned, CMS implements several value-based programs; HRRP and the Hospital VBP Program are most significant for case managers. HRRP reduces payments to hospitals with excessive readmissions within 30 days of discharge for specific procedures and diagnoses. The VBP Program adjusts payments to hospitals based on their performance across the four areas mentioned in the previous section.
Case managers play a crucial role in value-based care through practices that directly influence quality metrics and cost containment. Hospitals and healthcare organizations that effectively utilize case management are better positioned to succeed in this environment. Case management practices impacting value-based care include:
Care coordination – By facilitating communication between providers and ensuring that care is delivered in a timely and appropriate manner, case managers help prevent gaps, duplication, and delays. This improves clinical outcomes while reducing unnecessary utilization and costs.
Transitional planning – Case managers’ planning and oversight of care transitions between care settings reduces readmission rates, a key metric in value-based programs. Effective transitional care ensures proper information transfer, medication reconciliation, appropriate follow-up appointments, and client/support system education.
Discharge planning – By beginning discharge planning on day one, case managers facilitate a safe and timely discharge, improving efficiency and reducing costs while maintaining safety.
Resource management – Case managers directly impact efficiency metrics by evaluating the necessity and appropriateness of services and ensuring clients receive care at the right level in the most cost-effective setting.
Content adapted from CCM Certification Made Easy, 4th Edition by Deanna Cooper Gillingham, RN, CCM, FCM (2025) and used with permission from the Case Management Institute. Purchase your copy at CCMCertificationMadeEasy.com
