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As healthcare systems move further into value-based care, case management departments increasingly will need to focus on providing support to at-risk populations.
Case managers should learn how to better work with patients most vulnerable to hospitalization and build relationships with them, says Rebecca Perez, BSN, RN, CCM, director of product development for Fraser Imagineers and the Case Management Society of America (CMSA). She also is the executive director of the CMSA Foundation.
“When you’re working with individuals at high risk, they’re at high risk because they face multiple challenges, and often those challenges are social,” Perez says. “By developing a trusted relationship with them, you can better address those challenges. Sometimes, working on those challenges first helps them achieve better health outcomes.”
And the need to build trust is important when dealing with other healthcare professionals and case managers. For instance, another challenge for hospital case managers is learning to work with payer and community case managers, she notes.
There have been cultural and some structural obstacles to case managers communicating with each other between the hospital, community, and payer settings, but this should change, Perez says.
“Especially with the way reimbursement is going to value-based payment and team-based approaches, case managers — regardless of the practice setting, and with information that’s going to be shared and not isolated — all have to think about what’s best for the patient,” she says.
“If you’re hospital-based, you only have that episode, and there has to be a handoff somewhere,” Perez explains. “Whether it’s to an insurance-based case manager or long-term care, there has to be that handoff.”
This is why it’s so important that hospital case managers learn to develop trust as they communicate patient information to the next provider and case manager, she adds.
Perez suggests case managers facilitate better handoffs and relationships throughout the care continuum by following these suggestions:
• Build trust. The way to do that is to reach out to payer partners, developing relationships and processes for physicians. This can be through embedding case managers in facilities’ transition teams.
“It’s easier to build a relationship if you have a face, a physical presence, rather than just a phone and utilization review manager to talk to,” Perez says.
Case managers can develop relationships and build trust with payer groups, as well. This helps with transitions.
“They’ll know who they’re talking to and who they’re dealing with,” Perez says.
“If they don’t reach out to you, then you reach out to them,” she adds. “If the hospital case manager waits for the payer to reach out, and vice versa, then no one will accomplish anything. It’s about being proactive.”
• Reach out to payers. After years of distrust between hospitals and payers, it is time to get rid of that culture and focus on the patient. Case managers can be the first to take the initiative, Perez says.
“There are situations where certain payer structures are strictly telephonic,” she says. “Now, the trend is moving toward doing more face-to-face interactions.”
Payers might still only interact with hospital case managers and providers through conference calls, but relationships can build on that interaction as well. Case managers can offer to introduce payers to the transition team and discuss discharge planning processes, Perez says.
“That relationship gets established and each person knows who they’re working with and who the payer team is,” she says.
• Talk about alternatives. Case managers should have a list of available options. When a patient does not want to go to a long-term care facility, his or her case manager should be able to offer an alternative plan that allows him or her to stay at home with all necessary supports, Perez says.
The case manager can say to the payer, “We believe this support will prevent her from being readmitted, and it will save money over the long-term care facility. Would you be open to that?” she says.
It helps to collect cost and outcomes data. The case manager might bolster the case by adding, “You will save 17 days of skilled nursing facility per diem costs by having these services in place,” she explains.
“The hospital case manager needs to put that plan together and present it to the payer,” she says. “It helps to have trust between professionals and the patient.”
With trust, everyone knows they are working for the same goal of improving the patient’s care.
• Be quick to respond. “The strategy I always used as a case manager was to make their job easier,” Perez says. “I said to physicians and peers and colleagues that I would do whatever I could to support them and to make their jobs a little easier.”
And when someone called for a quick turnaround favor, Perez would come through on her promise.
“Even after I stopped working in the field, I would still get calls from facilities, saying, ‘I got a transplant patient, will you be the case manager?’ and that was years later,” she recalls.
“That’s how it works,” Perez adds. “When they know you are legitimate in your role to support them, then those relationships last.”
The key is to be genuine when telling other professionals that everyone is in this together to support the patient and the treatment plan.
Of course, it will not work unless the case manager follows through. “If you’re not flexible, you won’t last in the field of case management,” Perez says.
“I’ve recruited many case managers over the years that I thought would be really good case managers because they were so good with patients,” she says. “But they were far too rigid, and if you’re task-oriented, you won’t be a successful case manager when it comes time to fly by the seat of your pants because things change, especially when working with at-risk populations.”
With at-risk patients, something might change within minutes, and the case manager must be able to adapt to that change.
“You can have a beautiful care plan lined up and ready to go, and then everything falls apart,” Perez says. “So you have to alter that care plan and not see it as a failure because you’re always thinking about what’s best for the patient.”
Anticipate what can potentially go wrong, and always have a back-up plan. Flexibility is imperative in case management, she adds.
• Provide value-based care. Regardless of what happens with the Affordable Care Act, the focus on value-based care will continue to grow, Perez predicts.
“Personally, I see us finally on the right track of paying for performance, rather than just having fee for service,” she says. “We’re finally putting patients at the center of what we are doing.”
This transformation is an adjustment for many healthcare professionals and institutions. Some organizations are developing quality measures and moving toward standardization. And they recognize the importance of case management as the foundational support of value-based care.
“Truly, case management is at the heart of value-based payments,” Perez says. “It’s all about team-based care and care coordination, and case managers have always done that.”
Health organizations’ roles of patient navigators, patient advocates, and transition coordinators are all functions of case management, she adds.
“These are all functions of case management that people are piecemealing into great, innovative programs,” she notes. “We want to tweak something to make it look fabulous when we have something that works — case management — already in place.”
Financial Disclosure: Author Melinda Young, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher, and Nurse Planner Toni Cesta, PhD, RN, FAAN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.