As healthcare reform evolves, CM opportunities are increasing

Focus is shifting to transitions in care

As payers and providers grapple with ways to ensure that people obtain the healthcare services they need to stay healthy and to keep rising costs down, it's a good time to be a case manager.

"The Patient Protection and Affordable Care Act has put case management in the spotlight," says Cheri A. Lattimer, RN, BSN, executive director of the Case Management Society of America, (CMSA) with headquarters in Little Rock, AR. "We know that smooth transitions are important as patients move through the continuum of care. It's the case managers supporting the collaborative team who are going to help make the difference in providing appropriate transition planning, and educating patients and caregivers to help them become good care partners with their providers."

In the future, case managers will work in every healthcare environment where there is a transition of care: skilled nursing facilities, long-term acute-care hospitals, home care agencies, and hospices, predicts Catherine M. Mullahy, RN, CRRN, CCM, president and founder of Mullahy and Associates, a case management consulting firm based in Huntington, NY. "As patients move from one level of care to another, they need to know what to do in order to be successful at the next level," she adds.

Being a healthcare educator and advisor to patients as they navigate the healthcare maze is an opportunity case managers haven't had in the past, she says. Case managers can help people understand their diagnosis, make informed choices about treatment options, prevent complications, and save money at the same time, she says.

Lattimer points out that case managers are already located in many entities, for the hospital to the payer side, and the skilled nursing facility to hospice. "Case managers are the connective thread in the continuum, and healthcare executives are beginning to recognize the value they bring. There's a need throughout the continuum of care for experienced case managers to help people navigate the healthcare system, get the resources they need, and stay healthy," she says. (For information on some of the new opportunities for case managers, see related article, below.)

Mullahy adds that reductions in reimbursement and an increase in public reporting of healthcare data challenge providers at all levels of care to provide high quality care in a cost-effective, efficient manner. For example, initiatives from the Centers for Medicare and Medicaid Services (CMS), such as value-based purchasing, reward providers for high quality care and penalize those who fall short when compared to their peers. The Medicare Recovery Audit Contractors (RACs) are carefully scrutinizing hospital records for inappropriate payments. When the Medicaid RAC program goes into effect Jan. 1, 2012, their focus will also include outpatient treatment, home health, durable medical equipment, and other post-acute providers. The same kinds of practices are likely to be adapted by commercial payers as well, Mullahy says.

"There are a number of websites, including CMS Hospital Compare and Health Grades, that rate providers are on how well they manage patient care. Consumers are using these sites to determine where they will receive care, and commercial payers are also paying attention. It is obvious that in the future, providers whose services are more efficient and effective are the ones that are going to prosper," she says.

The focus on healthcare outcomes and efficiency means someone has to make sure that patients move quickly and safely through the continuum of care, and that they get the services they need, but do not incur unnecessary healthcare costs. Hospitals are recognizing that they need to follow patients beyond their front door, Mullahy points out. "Research shows that healthcare providers need to provide better transitions when they hand a patient off to the next level of care. Case managers talking to their peers at the receiving organizations are the best way to handle that," she says. "Hospital case managers can't manage all of a patient's needs after discharge. Case managers are needed in home care agencies, skilled nursing facilities, and other post-acute providers."

Healthcare reform and the emphasis on transitions between levels of care has opened up new opportunities for case managers who want to get back to a one-on-one relationship with their patients, Mullahy adds. Many case managers who went to nursing school to take care of people, are spending their time reviewing charts, entering data into a computer, and making telephone calls rather than spending time with patients.

"Patients often feel that their physicians are too rushed to take the time to listen to their problems and help solve them," Mullahy says. "The complex healthcare system and increasing use of technology is creating a disconnect between providers and patients. Patients are crying out for personal connections and case managers have an opportunity to fill that void."

Sources

For more information, contact:

  • Cheri A. Lattimer, RN, BSN, Executive Director of the Case Management Society of America, Little Rock, AR. E-mail: clattimer@acminet.com.
  • Catherine M. Mullahy, RN, CRRN, CCM, President and Founder of Mullahy and Associates, Huntington, NY. E-mail: cmullahy@mullahyassociates.com.

CMs are needed across the continuum

In today's changing healthcare environment, case managers have opportunities throughout the continuum of care, and those opportunities are only going to increase, says Cheri A. Lattimer, RN, BSN, executive director of the Case Management Society of America (CMSA), with headquarters in Little Rock, AR.

The patient-centered medical home model offers tremendous opportunities for case managers to work in the physician office setting. "When they work in a primary care or specialty physician office, case managers can be a health coach, a resources coordinator, transition coach and a healthcare educator, and coordinate with the treatment team to move to that patient-centered model of care," she says.

In today's healthcare environment, physicians don't have the time to give complex patients the time and attention they need to manage their conditions or illnesses, says Catherine M. Mullahy, RN, CRRN, CCM, president and founder of Mullahy and Associates, a case management consulting firm based in Huntington, NY. In the medical home model, case managers have the opportunity to identify and work with the patient population that needs help navigating the healthcare continuum, and learning how to manage their disease, Mullahy says. "There is a definitely a need in group medical practices for someone who has the knowledge, the skills, and the time to help patients access community resources, learn about their medication regimen and treatment plan, and ensure that they have recommended tests and procedures," she adds.

Major insurance carriers are also embedding their case managers into group medical practices to manage at-risk patients, Mullahy says. "Insurers and providers will both benefit when they work well together and help patients manage their chronic conditions and stay out of the hospital," she says.

Lattimer reports that one of the fastest growing areas of membership in CMSA is independent case managers who work contractually with payers and employers, or directly with patients and family members. As healthcare becomes more complex, consumers are hiring independent case managers to help them navigate the healthcare system, she adds. "The healthcare system is quite complicated, and often people need help in navigating all the parts of the continuum," Lattimer says. "The patients or their family members hire an independent case manager to work as their advocate and to ensure continuity in care."

Independent case managers can help people understand their diagnosis, make informed choices about treatment options, manage their medication regimen, prevent complications, and save money at the same time. "Patients and family members need an advocate to guide them in making the right choices and following their treatment plan," Lattimer says.

Independent case managers also have the opportunity to contract with a group medical practice that doesn't have an on-site case manager, but need someone to coordinate care for their most complex patients, she adds.

Mullahy says that as the baby boomers age, the demand for geriatric case managers is on the rise. "So many seniors live in a different city from their children and grandchildren and it's difficult to understand and manage the needs of the elderly from a distance," she says. "They can contract with a geriatric case manager to make sure their loved ones follow their treatment plan and stay safe at home."

Lattimer points out that as the value of case management is recognized, jobs are being created in brand new settings, such as big companies. "With the emphasis on wellness in the workplace, large employers are using case managers to work with their employees on managing their chronic diseases and staying healthy," she says. Numerous opportunities exist for case managers in the wounded warrior programs and other areas of the military, Lattimer says. Nurses can join the service and be on active duty, or they can be a contractor, she says.

Medication reconciliation and medication therapy management are recognized as being keys in helping patients manage their chronic diseases, Lattimer points out. Some retail pharmacists have employed nurse case managers to improve education and support for patients, she says.

As people travel out of the United States for healthcare, they might need a care coordinator to help them make the transition back to their country and to ensure that the providers who follow-up have all the information they need, she says.

In some settings, case managers are on the executive career track, Lattimer says. "I see case managers being groomed to be chief executive officers of hospitals or to assume other executive positions within the healthcare world. We're not done seeing where case managers can go," she says.