Evolution in the healthcare industry brings greater need for case management services — but also results in more obstacles and challenges in how case managers accomplish their goals.

• Payers sometimes choose lower-cost options, which could backfire if patients are readmitted to the hospital.

• It is difficult for case managers to help patients meet all of their needs, especially with the focus on social determinants of health and behavioral health challenges.

• Case managers need support from their leaders as they work to help patients overcome barriers and transition to the optimal setting.

The healthcare reimbursement landscape continues to evolve, and changes mean more roles for case managers and more attention on outcomes.

A major impact of the funding shift is that many individuals are underfunded for their medical care needs. They require care coordination when they transition between levels of care — and the needed resources might not be available, says Jose Alejandro, PhD, RN-BC, FAAN, president of the Case Management Society of America (CMSA) National Board 2018-2020. Alejandro also is the director of care management at the University of California, Irvine Medical Center.

“Their medical care is impacted by reimbursement methodologies,” Alejandro says.

Payers might choose to pay for a lower-cost option when patients are transitioned to the community. For example, at-risk patients discharged from the hospital might need physical therapy in a rehabilitation hospital or skilled nursing facility (SNF). Now, payers select the least costly option of sending these same medically precarious patients home to receive outpatient physical therapy or home health services that include physical therapy, Alejandro explains.

“Payers have eliminated a step in care transition, and the amount of time within each step also has gone down,” he adds.

This is a problem for health systems and case managers, but also for accountable care organizations and other payers.

The trend of cutting corners on post-discharge care could result in 30-day readmissions, meaning health systems will not meet their metrics to avoid financial penalties, says Rebecca Perez, BSN, RN, CCM, director of product development and education for CMSA and executive director of the CMSA Foundation.

“When that starts to bite the facilities with penalties for readmissions, I think you’ll start to see that change, as well,” Perez adds.

Medicare reimbursement shifts since the Affordable Care Act (ACA) became law have tasked providers with keeping patients stable, healthy, and out of the hospital — while also reducing overall medical costs and achieving optimal quality and outcomes.

Readmission penalties have been in place for several years, but healthcare organizations continue to see far too many patients readmitted, says Catherine M. Mullahy, RN, BS, CRRN, CCM, president of Mullahy & Associates in Huntington, NY.

“When discharge planning is done without any follow-up, too often patients are experiencing confusion about instructions for their treatment, symptoms to report, follow-up care, etc.,” she says.

When resources are limited, it is even more important that case managers collaborate with others inside their organizations as well as with their community partners, Mullahy says.

“No one healthcare organization can provide everything our patients need — especially when so much of that might be within the social determinants and behavioral health areas,” she adds.

Case managers are lynchpins in meeting the goals of greater efficiency and better outcomes. These goals are achieved when care transitions work well and patients are engaged in maintaining their health.

“Most organizations are looking at how to improve the patient experience and reduce overutilization of services,” Alejandro says. “One thing the ACA did was ensure there were enough case managers and social workers to address medical and psychosocial needs so patients would transition through the healthcare system more efficiently.”

The challenge is that a patient who is discharged too early might become ill again and have to be readmitted, Alejandro says.

“If the care coordination wasn’t set up appropriately, then you may see patients coming back,” he adds.

For these reasons, case management and care coordination need to have a voice in transition structures. Their input is needed to balance the goals of lowering costs and improving quality.

“Case management needs to be recognized as a valued resource to be utilized on behalf of those patients who are most at risk to themselves and to the organizations that are providing and/or paying for the care and services they receive,” Mullahy says.

“Unfortunately, there still is a shocking disregard for the true value of case management,” Mullahy adds. “Value translates into the acknowledgment of educational support and funding for the contributions that case managers make.”

Case managers need to be proactive in advocating for their patients to have realistic transitions of care. This includes addressing any social determinants of health that might be barriers to patients visiting their primary care providers, Alejandro notes.

“Case managers can make sure patients have social support from families and friends so their recovery is on track,” he adds.

Research shows that social determinants of health, including social isolation, impact people’s health, says Eboni Green, PhD, RN, co-founder of Caregiver Support Services in Omaha, NE.

“In fact, researchers suggest that maintaining poor social networks could have the same psychosocial and biomedical risk factors as cigarette smoking,” Green says.

Poor social support is associated with increased mortality, depression, physical health problems, and other health-related issues, she adds.1

Organizations that are proactive in ensuring patients’ well-being is assessed and their needs are integrated into the patient care plan likely will see the best outcomes, Green says.

“A robust care transition program that includes access to community resources, including patients and caregivers, combined with one-to-one communication between care managers — from both the transitioning hospital and the homecare organization — is also vitally important,” she explains.

For example, Green recalls working with a patient transitioning from hospital to home. The patient’s primary care need was wound care.

“It was a complex wound, so we worked with the hospital so that the patient’s wound care treatment could be observed by the case manager and the primary nurse,” she says. “The patient had recently been readmitted to the hospital after going home for a short time.”

The important question was “Why?”

Green helped find the answer: “We were able to determine that another component of her lack of healing was that the patient was isolated when she was home.”

The solution was to ask for help from local organizations.

“We were able to reach out to the local Office on Aging to get a volunteer to visit the patient three times a week,” Green says. “She was also placed with Meals on Wheels.”

This combined approach of discharge planning, community support, and nursing visits worked effectively and achieved the desired outcome, Green says.

Case managers might not be able to develop such a detailed plan for every patient, but this example shows how implementing an effective transition plan can lead to better outcomes and reduced hospital readmissions, she adds.

For case management to work most effectively, case managers need strong leaders who know exactly what their role is and how they can best fulfill it, Green says.

“Case management leaders in an increasing number of organizations are now those with business degrees who have little to no experience in case management and therefore lack the true understanding of the role of the case manager,” Mullahy says.

“Possessing experience and education in business and healthcare administration is certainly an important factor, but without experience in case management, departments and their staff are left without strong advocates for their role and the contributions they could obtain,” she adds.

And there should be a focused approach to care coordination, Green says.

Up-front work during the planning process can make a big difference in patient outcomes, and this approach is cost-effective and important for long-term outcomes, she adds.

Case management integration, collaboration, and coordination will help organizations achieve the triple aim of improving the care experience, improving population health, and reducing the per capita cost of care, Mullahy says.

“And, hopefully, it will assist in the recognition of the contributions made by case managers, whose mission is so well aligned to these objectives,” she adds.


1. Seeguert L. Social isolation, loneliness negatively affect health for seniors. Association of Health Care Journalists, March 6, 2017. Available at: http://bit.ly/2FMl8XM.