Since health insurers first developed case management programs in the 1980s, the marketplace for case management has evolved and changed across the continuum of care, with one possible exception: hospital settings.

“Care management models in the hospital have not kept pace in the marketplace. They’re still functioning in the 1990s market,” says Stefani Daniels, RN, MSNA, CMAC, ACM, founder and managing partner of Phoenix Medical Management in Pompano Beach, FL. Daniels writes articles and a blog about case management, and has been involved in the industry since the 1980s. She has spoken about value-based care management at regional and national conferences, including the Case Management Society of America’s (CMSA’s) June 26-30, 2017, Transformation of Case Management conference in Austin, TX.

The intent of case management and its focus on value-based patient care were hijacked several decades ago when diagnosis-related groups (DRGs) were implemented and resulted in a financial freefall for hospitals, Daniels says.

DRGs became a reimbursement management system that shifted payment away from a cost-based system to a prospective model in which payment was based on diagnoses. So, instead of being paid for what it cost the hospital to provide care, it was paid based on the illness and diagnosis of each patient.

“Hospitals that survived DRGs called in management engineers,” Daniels says. “They felt that in order to survive the DRG payment model, they had to quickly reduce costs.”

The management engineers came up with a plan that integrated the utilization review department with the social work department, she says. “With a little fairy dust, they created the case management department.”

“Before engineers got involved, hospital case management was basically a nursing practice delivery model,” Daniels adds.

Once case management departments — which used social workers — were founded, social work departments were seen as redundant and were eliminated.

“I was there, and many executives at hospitals believed social workers were a luxury. They believed that there were rare events where you needed a social worker,” Daniels says.

Meanwhile, the new case management departments moved away from the original focus of following patients as they traversed acute episodes of care, she says.

“That’s where we were, back in the 1990s,” Daniels says. “We had this thing called case management, but the original intent of coordinating care got lost in the shuffle, and we’re left with case managers who were doing utilization review and/or discharge planning.”

And that’s why hospital case management largely is stuck in the 1990s during an era when transformational changes to healthcare are making it more important than ever that case managers return to the original intent of following patients through the care continuum to improve both quality of care and efficiency, she says. Case managers in community settings are at the evolutionary front, but not hospital case managers.

“A director of case management at a hospital recently told me that case managers are going to be the wallflowers of population health,” Daniels says.

Around 2000, some hospital case management programs evolved to focus on outcomes in response to national news about patients dying due to medical errors. These often were places that could have a dedicated team of utilization review specialists, she notes.

“We started to see that case managers were working more closely with hospitalists to generate positive outcomes,” Daniels says.

After the Affordable Care Act (ACA) was passed in 2010, the value-based care model began to take off and include case management — at least, in community and industry settings.

“The vast majority, but not all, hospitals are still stuck in the 1990s model,” Daniels says, adding that she recently held a two-day workshop for a state hospital association and found that case managers at every hospital in attendance were involved in discharge planning and utilization review.

However, the future of case management can be seen in what leading health systems are implementing: “In more progressive hospitals, what we’re seeing is a movement toward patient-centered progression of care for high-risk patients,” Daniels says.

“Care coordination is too expensive to provide to everyone in the hospital, and it isn’t needed by most,” she adds. “What we’re seeing are new efforts for predictive analytics, so the hospital could come up with a statistical method to identify high-risk patients.”

Another turn toward the future of case management is a realignment of activities.

“Case management has always been a compilation of several activities, and it’s evolved that way since the 1990s,” Daniels says. “Things like psychosocial counseling, clinical documentation programs, revenue cycle activities, appeal team, denial team have been part of case management in hospitals.”

Now, it’s changing where some of these activities are leaving case management. For instance, an increasing number of hospitals are carving out the utilization review activity and moving it to finance departments, she explains.

“And that’s wonderful and makes sense,” Daniels says.

Hospital case management still focuses too much on discharge planning and seems to misunderstand what care coordination is, she notes.

“They will define care coordination as the discharge planning process and coordinating the need for transition, and that’s one small component of what care coordination is supposed to be,” Daniels says. “I have been to hospitals where care managers acknowledge that there are days when they never see a patient; they’re sitting in front of these computers, doing discharge planning and those logistics.”

Instead, all hospitals should focus on the future of case management as patient-centered care coordination that focuses on improving patients’ health, she says.

Rather than having patients speak with a case manager on one unit and then with a case manager on another unit, there should be a single, consistent resource for the patient as he or she moves through the hospital, Daniels says.

The following are some other ways case management should progress:

  • Case managers should promote safe, timely delivery of care.
  • Facilitate communication within a team and throughout the hospital and care continuum.
  • Intervene when a patient’s treatment plan goes against the patient’s and family’s stated wishes. Daniels recently saw a situation in which a 93-year-old patient and her family had agreed to forgo aggressive treatment. Their goal was to keep the patient comfortable.

Instead, the patient’s doctor was planning on open-heart surgery for her. “So, where is the case manager in this situation?” Daniels asks. “This family and patient had agreed to not have aggressive treatment for cardiac problems, and that’s what care coordination is all about. Case managers need to make sure the treatment plan reflects the patient’s and family’s preferences — a primary ethical obligation.”

Mostly, future case managers in all settings will need to focus on care coordination, Daniels says.

“That does include transition of care,” she notes. “And it includes true care coordination with general psychosocial counseling to make sure we can connect the patient as seamlessly as possible to keep them happy and to respond to their disease and illness.”