Case managers’ roles are evolving through focus on capitated models that focus on keeping patients out of hospitals and emergency rooms.

  • Case managers can help patients with medication reconciliation at a home visit.
  • They can learn more about patients’ obstacles to self-care through a conversational type of questioning.
  • Case managers can reinforce physician education by giving patients hands-on experience with using new devices or tools.

As health systems increasingly take on more financial risk in managing patient populations and lives, their role is evolving. The same is true for healthcare professionals, especially for case managers.

Their role is changing from one of solely helping patients where they are in the continuum of care to helping patients improve without transitioning to hospital and ED care. “We look at how we can keep the patient healthy and out of the hospital,” says Linda Violas, BSN, RN, CCM, director of clinical effectiveness in the division of care integration for St. Joseph Heritage Healthcare in Anaheim, CA.

“We have care managers help patients and get them into self-management if they need it,” Violas says. “We make consistent decisions and follow guidelines to wrap around decision-making and goals.”

Case managers increasingly will hear the phrase “evidence-based decision-making,” she says.

“Blue Shield gives us expanded capitation that covers hospitalization,” Violas says. “We pay for the high-dollar services ourselves, so we need to do a very efficient job of preventing readmissions and making sure patients are well-educated.”

Another aspect of handling population health under a capitated care or accountable care organization (ACO) arrangement involves using data to determine which patients would most benefit from case management. For St. Joseph Heritage Healthcare, the answer is to provide case managers to high-risk patients and those with catastrophic conditions.

“For example, people who are not managing their diabetes or who have chronic conditions of chronic obstructive pulmonary disease and congestive heart failure, we visit at home, spending 30 minutes to two hours,” says Elisol I. McKim, BSN, RN, CCM, nurse care manager with CARE Connect of St. Joseph Heritage Healthcare.

McKim’s goal is to try to understand why patients are having difficulty managing their diseases. Is it their medications? Are they taking the wrong ones, such as prescriptions that are old and should be discontinued?

“Here’s the patient’s primary care physician giving this medication, and another doctor is giving her another medication, and we need to reconcile them,” McKim says. “I’ve seen patients who are doubling their medication prescription or taking the wrong medication.”

Other patients are taking over-the-counter pills and herbal products that are contraindicated for their prescribed medications, she adds.

Sometimes it takes a home visit to resolve these issues.

Another benefit of the case management home visit is how this can reinforce the self-management training doctors and hospital providers have given the patient. McKim says a good example of how this additional instruction can be beneficial is with diabetic patients, who often dislike testing their blood sugar levels and might have trouble drawing and administering insulin.

“It takes a lot of teaching, and they might do better with pre-filled syringes, which are something we can provide for them,” McKim says. “When they’re in the doctor’s office, they have 20 to 30 minutes to learn all of the things the doctor said.”

But if a case manager introduces patients to a new device, such as a pre-filled syringe, the case manager also needs to show the patient how to use it because new technology can be stressful for some patients, particularly seniors, McKim notes. “The doctor can prescribe it, but who will teach them?”

Case managers also help patients make a habit of the daily actions they need to take to ensure their health is stable.

“When a patient has congestive heart failure, we say, ‘Ms. Smith, you should weigh yourself daily,’” McKim says. “Then you call the patient a week later and ask, ‘How is your weight? Have you lost or gained weight?’”

If the patient’s weight has gone up, McKim will suggest the patient visits his or her doctor, rather than waiting for the problem to worsen and result in an emergency room visit.

In working with elderly patients who have multiple chronic conditions, it’s important to know about potential mental health issues, family and friend caregiving resources, and their particular environmental and psychosocial situations, McKim says.

“My background is in geriatrics,” she says. “I started working in nursing homes with seniors.”

With this experience, McKim says she learned how to start conversations with patients that will elicit the kind of information that is most useful and can lead to insights into obstacles to maintaining their health. Having the opportunity to visit patients in their homes is crucial to the case management program’s success. (See story on improving communication with geriatric patients in this issue.)

“I believe in this care management program,” McKim explains. “This is how we should take care of patients: building relationships and trust.”

In creating a role for case managers in the ACO model, the healthcare organization merged divisions of hospital and outpatient case managers to more effectively manage patient care, Violas says.

“Now all these case managers work for the outpatient sector with one central vice president and leadership,” Violas explains. “More than 300 people do care integration, which includes everything from training, standards, utilization management, inpatient and outpatient reviews, quality management, and we have a technical arm.”

Case managers who meet with patients in their homes have goals to improve symptom management and engage patients into better self-care and health management, Violas says.

The program, with its strong case management focus, has been successful, she notes. “We’ve saved quite a lot of money — $1.4 million per year — through the ACO arrangement and through case management.”

The case management program also has resulted in reducing hospital readmissions by 9%, Violas says.

“We do very well with diabetes care, keeping good A1C rates throughout the population,” she says.

If data show that patients in some groups of care have better outcomes than other groups, leaders look at the better-performing group’s best practices to see if these can be used by the other groups as well.

“We’re still learning, finding out what to do,” Violas says. “We first have mutual goals to strive for, and then we take those goals and press them further because with ACO contracts, you have to up your performance each year, step up your game.”