By Melinda Young, Author


Payers are moving toward longitudinal or value-based care across the care continuum, but health systems are lagging in building an infrastructure for this newer model.

  • Hospitals and case management departments too often operate under the philosophy of discharging patients and finishing those cases.
  • There is wide variation in where health systems are on the continuum of change to accountable care, longitudinal care, and population health initiatives.
  • Value-based care provides quality care at the right place with optimal patient satisfaction.

One way to view the healthcare industry’s transformation from fee-for-service to value-based care is to think of it as a change from the episodic model of care to a new model of longitudinal accountability across the care continuum.

At least, that is what hospitals should be thinking about. “Hospitals are a little behind on the concept of longitudinal care management,” says Kathleen Ferket, MSN, APN-BC, senior consultant with Ferket Advisory Services in Chicago. Ferket speaks about longitudinal care at national case management conferences.

“Hospitals have been long rooted in the episode of care, and they’re doing a good job with discharges to the next setting,” Ferket says. “But it’s really saying, ‘We’re done with that patient and on to the next.’”

By contrast, payers have been attending for a long time to longitudinal care management with chronically ill and complex patients. They are ready for this transition, waiting for health systems to catch up.

“There are a lot of disrupters in the market,” Ferket says. “So those areas across the business sector that have embraced the disruption have done a better job.”

Accountable care organizations (ACOs) are one way that acute care hospitals have moved into the longitudinal care management arena. This is especially true for health systems involved in the Medicare Shared Savings Program, called Pathways to Success. (See story about Pathways to Success in the April 2019 issue of Hospital Case Management.)

Some physicians, EDs, and hospitals are committed to the process of reducing costs for Medicare patients.

Those involved with Pathways to Success do their best to navigate patients to the best level of care and to keep patients out of the hospital, Ferket notes.

There mostly is a wide variation where health systems are transitioning to longitudinal care management.

“Everyone is in transition; there are huge variations in philosophies around patient care management,” says George Mayzell, MD, MBA, FACHE, vice president and chief clinical officer of Vizient Southeast in Tampa, FL.

“Folks have dedicated different amounts of time and resources to thinking about this,” Mayzell says. “Slowly, most of the systems are coming to the realization that they have to get this right, that this is an important part of care practice across the hospital.”

While some hospitals still focus on utilization review and discharge planning, others are moving to a clinical case management model that includes care coordination, he says.

“Case management is an incredible asset to health systems,” Mayzell notes. “There are few people who get to see the patient at the bedside and follow them through the hospital so they can identify risk issues, quality issues, and social-economic issues of patients.”

The case management team should be clinical, but it also should integrate social workers and other disciplines, including pharmacists, nutritionists, and physical therapists, Mayzell says.

For hospital case management programs, a first step is to teach staff the definition of value-based care and longitudinal care.

“Value-based care initiatives are driving a lot of work being done right now, so make sure folks understand what we mean by value-based care,” Ferket says.

They also need to know the drivers behind longitudinal care, including the United States’ financial and clinical outcomes.

“Healthcare in the United States is more expensive than any other industrialized nation, and yet our outcomes are not as good,” she says. “We rank in the second tier.”

Value-based care provides quality care at the right place and ensures patients are satisfied with their care. It also means making sure all of a patient’s care providers have access to the same medical records, Ferket says.

“Care managers and case management divisions within health systems are coming to the forefront,” Ferket explains. “It’s no longer, ‘I’m going to worry about your length of stay and whether your hospitalization is going to be covered.’”

Instead, the focus is on transferring patients to the next level of care and keeping them within the system as much as possible, she adds.

“Case managers will look at a patient as someone they will keep on their caseload for the patient’s lifetime,” Ferket says.

Another strategy is to recognize that the patient leaving the hospital is transitioning to another setting and his or her care is ongoing, Mayzell suggests.

The case manager’s job is to educate patients and their families about their transition and the case managers, care coordinators, or transition coordinators who might be helping them along the way.

Directors also should select the best staff for case management in the new era.

“Some of the older models of case management emphasized nonclinical people, although they always had some clinical staff,” Mayzell explains. “But the new models — and I’m preferential to these — are a clinical process.”

The new case management role will be challenging because each hospital case manager will need to understand payment models and how to work with hospital physicians, outpatient providers, and payer case managers, he says.

“It requires extensive knowledge to do this role, and you have to understand clinical expertise and the disease process,” he adds. “Case managers now need more skills than utilization review and discharge planning; it’s a very difficult job.”

For a long time, healthcare organizations were siloed in their focus. Acute care staff would only learn how to handle patients in acute care and not necessarily understand what happened when a hospital discharged a patient to ambulatory care, Ferket notes.

“Case managers might not have known about resources in the community,” she adds. “Now, the opportunity to build those relationships across the continuum of care is key; case managers need to know the handoff is safe and they’re including the patient’s goals of care in that transition.”

It is about breaking down the silos in the ED and hospital and understanding the entire health system and community points of contact, she says.

Case management directors will need to hire staff who possess the right personalities and skill sets, and invest in training.

“There has to be integration of these roles with all key players in the hospital, including integration with nursing, physicians, and other hospital teams,” Mayzell says. “Establish a rapport with physicians so they can see case managers as assets and help them and their patients in the care process.”

It’s also crucial for directors to show their hospital leadership how important case management is as the health system transitions to longitudinal care.

“Make sure they understand the benefit of this,” Mayzell says. “It takes additional resources, and leadership has to buy into the model and provide enough staffing and training resources for it to be successful.”

The ultimate goal is for case management to be linked to quality initiatives and help the hospital reduce length of stay and readmissions, he adds.

The shift to longitudinal care management also requires leveraging technology, Ferket says. Some electronic health records have identified the importance of connecting ambulatory settings to acute care settings, she says.

With up-to-date technology, there are ways to make sure everyone who sees a patient is in the loop and understands where the patient is in the continuum of care, Ferket says.

By leveraging the electronic medical record, case managers can stay on top of what is happening in the acute care episode and in the skilled nursing facility. New technology enables bi-directional communication with patients, she adds.

This move toward longitudinal and value-based care is a trend that will continue regardless of what happens with the Affordable Care Act, Mayzell says.

“Most people agree that our current healthcare spending is unsustainable, and most people agree there is a lot of waste in our system. Clearly, there have to be some new payment models,” he says. “Value-based care will continue and not just in Medicare-driven arenas; this train is not going to stop.”

Hospitals that work now to establish infrastructure and strategies to handle these changes will be in better shape when the change is forced on them.

“You have to have some infrastructure things in place, including a good data and analytic system, as well as the right payment model and culture in the organization,” Mayzell explains. “Those are things you cannot pull together at the last moment, and making changes now will make you more successful in the current fee-for-service model, as well as in the future.”