Executive Summary

Due to the Affordable Care Act, the accountable care organization (ACO) model has grown in recent years, providing more opportunities for case management and greater demand for CM experts.

• Case or care managers assist in provider, payer, and other settings with helping patients avoid unnecessary hospital and emergency room care.

• Case managers who can speak Spanish are in great demand in some areas of the country.

• ACOs are changing the face of what case management does by providing a financial framework for creative solutions to patient barriers to better health.

 

Accountable care organization (ACO) and medical home models for Medicare and other patients have expanded in recent years due to financial incentives provided by the Affordable Care Act, and the result is a spike in demand for health professionals who can do care or case management type of work.

The Centers for Medicare & Medicaid Services (CMS) added 89 new ACOs in January 2015, for a total — including the pioneer ACOs — of 424 ACOs, serving 7.8 million beneficiaries.

ACOs are designed to improve care coordination and integration for Medicare beneficiaries. Many also have expanded to privately insured populations. An ACO is a collaboration between doctors, hospitals, and other healthcare providers. The purpose is to provide high-quality care meeting specified Medicare quality targets, and to share in any savings they can generate for Medicare, according to CMS.

“We’re at an interesting point in healthcare, where a lot of the financial incentives really are aligned to help us be creative and do things that are the right things to do, but previously we weren’t rewarded for doing those things,” says Ann Kirby, MSN, MPA, BSN, regional director of care management for Oregon at Providence Health & Services in Portland. Providence has a connected care contract, which places a heavy emphasis on team-based care, coordination, and online records and scheduling.

ACOs are changing the face of what case management does, says Morey Menacker, DO, president of Hackensack Alliance ACO in Hackensack, NJ.

“I think costs and quality go hand-in-hand,” Menacker adds. “There are different reasons why people form ACOs, but if you’re truly trying to change the care mechanism then what you need to have is someone who is the point person behind the patient’s whole healthcare experience.”

Increased demand for case/care managers has led to staffing problems for ACOs, says Chris Senz, chief operating officer at Tuality Health Alliance in Hillsboro, OR.

“It’s a nightmare, finding case managers,” Senz says. “There are not enough case managers.”

It’s even more challenging to meet the demand for bilingual case managers, she notes.

“We live in a county with a very large Latino population — 53%,” Senz says. “And we’ve had a position open for a Spanish-speaking nurse.”

It might be that all case managers need to learn Spanish, she adds.

Rather than English as a second language classes, CMs could use Spanish as a second language classes, she says.

“We partner with universities for nursing students and nursing programs to help them attract people of different cultures, to help them build a pipeline,” Senz says.

As Providence Health & Services grows, there likely will be additional staffing challenges, Kirby notes.

“So far, we have been able to recruit people from other types of nursing roles or recruit people from different communities into care management roles,” Kirby explains. “I am guessing we’ll experience a shortage of people with care management experience, and we’ll have to do more intensive training and education to get people up to speed on the care management role.”

Finding experienced case managers (CMs) who are flexible in how they define case management is another challenge. A long-time CM might have a mindset and culture that is counter to what ACOs are trying to accomplish, Senz adds.

“A lot of case managers come out of a traditional healthcare/providing direct treatment environment, thinking, ‘How do we get them to the skilled nursing facility?’” she explains.

ACOs need case managers who can think outside the provider box, willing to develop common sense solutions that are unrelated to healthcare interventions and care.

Funding decision flexibility gives CMs room for creativity in problem-solving. Examples include providing air conditioning units to congestive heart failure patients who live in homes that become swelteringly hot in summer months, and providing hand-held shower wands to obese patients who might otherwise end up with wounds that require hospitalization, Senz suggests.

“I think it’s fun to see that creativity at work and to see case managers thinking about the whole person’s care — a total care model,” Senz says.

ACOs and patient-centered medical home (PCMH) models are focused on moving beyond traditional fee-for-service healthcare through creative solutions, notes Anna Meara, RN, MBA, associate vice president of Network Care Management at Montefiore Health System in Bronx, NY.

“We take collaboration with other healthcare providers to another level,” Meara says. “We’ve built a robust infrastructure at Montefiore that includes 600 people across our network.”

The organization manages a population of the highest risk and high utilization, she adds.

“We have a structured way of data mining to benefit people who would benefit from care management,” she says. “We also track discharges from all of our own hospitals and do utilization management.”

In the Montefiore system, a team of primary care physician sites and case managers direct the care of several hundred thousand people.

Case managers in emergency departments make referrals, and other case management takes place in primary care offices where teams identify patients who would benefit from medical home services, Meara explains.

“Once we identify people through outreach, we explain care management and do a comprehensive bio-psychosocial assessment to explain medical needs, medications, and to find out about other things in their lives, including their housing situation, child care issues, transportation issues, depression screening, fall risk screening, and palliative care screening,” Meara says. “We look at every aspect — a holistic approach.”

Case managers oversee patients’ care plans and are the primary point of contact. But they can pull in experts on a regular basis, Meara adds.

“If someone is suffering from depression, we can call in expertise in that area.”

There are multiple roadblocks to creative solutions, but ACOs give CMs a route to bypass them.

For instance, the old medical model, which is still the Medicare model, requires patients to have a three-day inpatient stay before they’re eligible for coverage at a skilled nursing facility, Kirby notes.

“Once, maybe having people stay in a hospital for three days made sense,” she says. “But now in our [ACO] plan we can place someone in the skilled nursing facility whenever it makes sense for that patient.”

ACOs allow for flexibility when dealing with a population’s health, she adds.

“A big part of this is the case manager,” Kirby explains.

“When you work with a population that ranges from extremely healthy and young to disabled, older, frail, and with cognitive issues, it’s not the care manager who is providing services,” she adds. “But the care manager is the one who is identifying people who need help and who might reach out to the person to set up a series of services.”

The case/care manager is the hub, the person who works at the point of transition and assists when patients are at a vulnerable point in their health, Kirby says.

CMs can provide risk assessment by telephone. While the goal is to identify problems that could lead to unnecessary hospital visits, the CM also can regularly call patients who have chronic diseases but are otherwise low risk, to help them manage their illnesses, Kirby suggests.

Case/care managers across settings need to coordinate and collaborate for an ACO model to work. Improved communication is important, Kirby says.

“We also need to determine who is the lead care manager,” she adds. “This can be something as simple as saying who is in charge.”

People in healthcare think of ACOs as a model for practicing population health, but it’s more than that, Menacker notes.

“What we’re trying to do is classify our program as a global healthcare experience as opposed to population health, because we’re not just looking at groups of people,” he explains. “We’re looking at individuals, and we realize we need to partner with the individual throughout the person’s life and in all interactions with healthcare professionals.”

This philosophy leads to sensible solutions, Kirby notes.

“An example is how in the fee-for-service system, Medicare does not pay for a certified nursing assistant. Medicare will pay for skilled services, but this creates a care gap for frail, elderly people who need home service,” Kirby says.

An ACO can choose to pay for the certified nursing assistant position, which might keep some elderly people out of the hospital and in their homes for longer than they would be, she adds.

ACO CMs pay particular attention to individuals with multiple hospital visits for avoidable problems. For example, a Providence Health ACO care manager identified that one patient had visited three different emergency departments in one day. Further checking revealed that the same patient had made 29 ED visits within the previous 12 months. These findings resulted in the CM connecting with the patient’s primary care physician to talk about the patient and develop a solution, she says.

Improving patients’ health through the ACO model also means directly asking patients and their families what they want as part of their care plan, Kirby says.

“A lot of times what is left out of patient care is asking patients and families, ‘What do you want? What is your plan of care? How can we help you be healthier?’” she adds.