Case managers need better tools more than ever before to manage patients in this era of population health and an all-inclusive continuum of care.
“Case management as a practice has evolved to acknowledge and recognize that it’s not just episodic and doesn’t have recognition of only one disease state with blinders on,” says Ellen Aliberti, MS, CCM, RN, clinical educator at Intermountain Healthcare — Nevada Market in Las Vegas. Aliberti also is the director of the Case Management Society of America (CMSA) of Las Vegas. “It has potential solutions and strategies to manage populations of health across many continuums of care and with key focuses on helping patients be self-reliant. Case management has always had advocacy at its roots, but case management now lives in a much broader focus.”
Case managers need tremendous tools to help them manage care of chronically ill patients along the continuum, she notes. It is important that case managers use evidence-based tools in their practice, outcomes, and decisions, Aliberti suggests.
“That’s a huge thing for all of us case managers to really be serious about because we’re probably not doing as good a job as we could as far as educating ourselves about evidence-based criteria and screening tools to help us make better decisions for our patients,” she says.
Here are Aliberti’s suggestions for which evidence-based tools to use and how to find new ones:
• Utilization management decision tools. “When case managers are working within settings where they have to make determinations about whether a patient can stay someplace or the level of care they need, then they should ask the facility for the criteria it uses and copy it,” Aliberti says. “We’re entitled to have that as case managers, but how many people ask about that?”
Also, case managers should obtain the criteria that payers use and compare that to the criteria used by the setting, she adds.
There are commercial utilization management screening tools as well, such as InterQual. (https://www.changehealthcare.com/solutions/clinical-decision-support/interqual) Another screening tool is the Milliman Care Guidelines. (https://www.mcg.com/)
• Seek guidelines from national associations. National websites for the American Diabetes Association, the American Health Association, and others include guidelines for screening and working with patients with these diseases.
For example, the American Diabetes Association (ADA) posted a Type 2 diabetes risk test on its website at: https://www.diabetes.org/risk-test. The organization also offers a diabetes self-management education and support consensus report for adults with Type 2 diabetes. That 2020 evidence-based report is an update of the 2015 joint position statement, found at: https://care.diabetesjournals.org/content/43/7/1636.
The ADA calls this method diabetes self-management, education, and support services, or DSMES. The report describes positive outcomes when DSMES is used. For example, one key clinical benefit is a reduction in hemoglobin A1c and a reduction in the onset and/or worsening of diabetes-related complications.1
Keeping up with guidelines and consensus papers is important for case managers and prevents them from becoming stale in their knowledge of evidence-based information, Aliberti says. Payers use evidence-based criteria to make decisions about authorizations for treatment. Case managers should be able to point to information that supports their requests for patients.
“You also need to be mindful of national screenings you can use to benefit your patients,” Aliberti says.
• Use PAM and health literacy screening tools. The Patient Activation Measure (PAM) is a valid and reliable scale that reflects the four stages of activation:
- Believing the patient role is important;
- Possessing the knowledge and confidence to take action;
- Taking action to maintain and improve one’s health;
- Staying the course under stress. (For more information, visit: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361049/.)
CMSA’s 2020 Case Management Adherence Guidelines (CMAG) highlight PAM in a section on engagement. (For more information, see the article in the May 2020 issue of Case Management Advisor at: https://www.reliasmedia.com/articles/146069-cmsa-launches-new-guidelines-for-case-management-adherence.)
“PAM is something CMSA has helped us learn about and encouraged us to use with our patients,” Aliberti says.
Another important tool can screen patients for health literacy. The Rapid Estimate of Adult Literacy in Medicine is a word recognition test that quickly provides clinicians with an assessment of a patient’s health literacy. (Find out more at: https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy/index.html.) Understanding a patient’s health literacy can help case managers identify adherence challenges, Aliberti notes.
• Screen for depression and anxiety. The nine questions in the Patient Health Questionnaire-9 (PHQ-9) can screen patients for depression, anxiety, and severity. (More information is available at: https://www.mdcalc.com/phq-9-patient-health-questionnaire-9.)
For instance, the first question is “Little interest or pleasure in doing things?” The choices are as follows:
- Not at all, which has a zero score;
- Several days — 1;
- More than half the days — 2;
- Nearly every day — 3.
“PHQ-9 is a great tool for depression and anxiety, which are understated in the populations we serve,” Aliberti says.
Case managers also should ask about loneliness, which always is a risk for older patients, but might be more pronounced during the pandemic and social distancing practices, she adds.
• Assessing fall risk. The Timed Up and Go test is a fall risk assessment tool. Patients sit in a chair, walk to a line on the floor, and then return to the chair. They are timed with a stopwatch. (A demonstration can be viewed at: https://www.youtube.com/watch?v=grrYoBucNPE.)
There are other screening tools that case managers can use as well. For instance, some healthcare organizations use their own checklists for assessing patients’ social determinants of health.
Case management assessments must be robust and include details such as patients’ physical limitations, behavioral health issues, and social determinants of health. “We now know that all of these social determinants of health are influencing our patients’ willingness, ability, and desire to be engaged with their health or not,” she adds.
When deciding which screening tools to use, case managers should base their choices on their patient population and whether the tools are evidence-based.
“Look at what are the tools we need to be aware of and incorporate into our practice to evaluate our patients’ willingness and ability to engage in care,” Aliberti says. “A majority of patients are being cared for in outpatient settings, and the focus is on self-reliance. Case management has opened our ability to influence in a number of different spheres.”
- Powers MA, Bardley JK, Cypress M, et al. Diabetes self-management education and support in adults with Type 2 diabetes: A consensus report of the American Diabetes Association, the Association of Diabetes Care & Education Specialists, the Academy of Nutrition and Dietetics, the American Academy of Family Physicians, the American Academy of PAs, the American Association of Nurse Practitioners, and the American Pharmacists Association. Diabetes Care 2020;43:1636-1649.