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2010 may bring new career opps for CMS
Value of care coordination is being recognized
Now is a good time to be a case manager, leaders in the field report. New opportunities are opening up for case managers as the country struggles with ways to provide optimal health care for everyone while minimizing soaring costs for care.
"Care coordination, case management, and safe transitions of care can only help save health care dollars. More and more, case management is being recognized as a valuable service and people are beginning to understand how the care coordination piece benefits the bottom line," says Margaret Leonard MS, RN-B, C, FNP, senior vice president for clinical services at Hudson Health Plan in Tarrytown, NY, and president of the Case Management Society of America (CMSA).
All of the health care reform bills that were introduced in Congress include the concepts of care coordination, care management, and safe transitions of care as cost and quality essentials for health care, Leonard says.
In addition to giving input on health care reform proposals, CMSA has been asked to provide language for a model case management act, she adds.
The Case Management Model Act is not a bill, but rather a document that educates legislators and regulators to help them define criteria for care coordination, case management, and transitions of care. It includes case management standards of practice, which contain a list of criteria that must be met before someone can call himself or herself a case manager, Leonard says.
"I feel good about the health care reform measures as they apply to case management. I think they will open up new avenues of practice for us. I don't think primary care physicians or other providers who don't already have case managers on staff will not go start hiring them until something is decided about health care reform including the realignment of incentives; but once we get past this hump, we're not going to see any problems with nurses and social workers getting positions," Leonard adds.
Nancy Skinner, RN, CCM, agrees that case managers will have new opportunities in the future.
"It's going to be a whole new world for case managers. The case manager is going to become a consultant who helps the patient, the family, and caregivers have quality of life through the end of life," says Skinner, a consultant for Riverside HealthCare Consulting in Whitwell, TN.
Some of the opportunities for case managers will depend on what the final health care reform legislation looks like, Skinner says.
For instance, the idea of a patient-centered medical home is under discussion, and is likely to involve case managers in some way, Skinner says.
However, there's still no agreement on how physicians will be reimbursed for providing the extra services to patients, she points out.
"In today's economy, we truly need to focus on appropriate case management, but it all depends on the funding. I believe that case managers will become a part of primary care practices, but it may take as long as five years to determine how the patient-centered medical home is going to be organized and how case managers will participate," she says.
The incentives have to be aligned appropriately for primary care physicians to add case managers to their practice, Leonard adds.
"We can't ask primary care physicians to provide care coordination and not receive increased reimbursement. They're going to have to hire staff, and the government is going to have to reimburse for it," Leonard says.
The medical home model includes case managers who work with physicians to manage the care of patients, something that is sorely needed, adds Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy & Associates, a case management training and consulting company.
"The health care system has become so complex that people need someone to act as their advocate. As physicians are forced to decrease the time they spend with patients in their office, and more responsibility shifts to the patient and family members, people need someone to guide them in making the right choices and following their treatment plan," Mullahy says.
Case managers can help people understand their diagnosis, make informed choices about treatment options, prevent complications, and save money at the same time, Mullahy says.
"However, the average person doesn't understand how much help a case manager can be, and that's why we need to educate them," she says.
Case managers based in physician offices can help patients understand how to manage their condition, how it will improve their quality of life if they do, and what could happen if they don't, says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, case management consulting firm.
"We hear so much about noncompliant patients who don't fill their prescriptions and don't take their medications correctly, but there is very little education that occurs at the doctor's office level when a new prescription is ordered or a new diagnosis is made. Patients need to be educated about how to adhere to their treatment plan, and case managers are the right people to do so," she says.
Sometimes patients can't afford their prescription and need help looking for alternatives, Kizziar points out.
"Doctors decide what is appropriate and rarely ask if the patient can afford it. I think people leave the doctor's office without the knowledge they need to make the kind of decisions they need to make. This is another opportunity for case managers," she says.
Whatever happens with health care reform, it is likely to be more and more difficult for middle-sized and smaller employers to continue to provide the same kind of health care coverage they do today, and that is likely to create opportunities for case managers, Kizziar points out.
She sees opportunities for case managers either as consultants on a contract basis or as employees who can help employees navigate the health care system, she says.
"As more and more people shop for health care benefits, case managers have an opportunity to share their expertise and act as consultants to employees to help them make wise decisions," she says.
Being a health care educator and advisor to help employees navigate the health care maze is an opportunity case managers haven't had in the past, she says.
"I have believed for a long time that case managers should inform the health care consumer about how to make better decisions and how to be compliant. This is going to be even more important in the future," Kizziar says.
The complex health care system and the emphasis on efficient and effective care already is creating opportunities, Mullahy points out.
"More and more third-party administrators are bringing case management and disease management programs into their organization. Employers are starting to look at opportunities for case managers. Hospitals are advertising for nurse navigators to help patients navigate their way through the health system and to manage their care once they are discharged," Mullahy says.
With the current emphasis on readmission rates, case management responsibilities in the acute care setting are likely to expand, and extend into the community, Skinner says.
"The focus on readmissions is going to increase the value of case managers and create a greater need for case management," Skinner says.
Data compiled by the Centers for Medicare & Medicaid Services (CMS) show that about 20% of patients responding to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) replied no when asked if anyone told them what they needed to do at the next level of care, Skinner points out.
"As health care reform rolls forward, I see case managers taking a role after patients are discharged from the hospital to help prevent an adverse event that could result in a rehospitalization," Skinner says.
For instance, heart failure is a major cause of rehospitalization within 30 days of discharge, Skinner says.
"Case managers can have a significant role in working with these patients to prevent readmissions. I predict that in the near future CMS will announce an intention to modify or discontinue payments for readmissions within 30 days. If and when this occurs, hospitals are going to have to develop a case management program for heart failure patients after discharge, or they're going to lose reimbursement from Medicare. Case managers in acute care are going to have to pick up a much greater role in transitions of care," she says.
Skinner predicts that in the future, case managers will work in every health care environment where there is a transition of care skilled nursing facilities, long-term acute-care hospitals, home care agencies, and hospices.
"As patients move from one level of care to another, it's going to be the responsibility of the facility discharging them to give them the tools they need to be successful at the next level," she adds.
The aging baby-boomer population is going to be the catalyst for change, she adds.
"I can see case managers working in clinic environments and educating patients on what is wrong, what the patient needs to do, and why it is important," Skinner says.
For instance, joint replacement patients could benefit from having a case manager work with them before surgery, during the hospitalization, and after discharge, she adds.
Case managers can help with transitions of care by facilitating communication between providers and making sure providers at each level of care have all the information they need to treat the patient.
"Many times, patients are seeking care from many different providers who don't always communicate with each other," Leonard points out.
For instance, if a patient is hospitalized or sees a specialist, the family doctor may not know what has been going on.
With the current system, if the primary care physician refers a patient to a specialist, that doctor should get the information back to the primary care physician. It doesn't always happen because no one is responsible for sending the information or ensuring that the primary care physician receives it, Leonard points out.
"In the future, because of the economy, many different levels of providers are going to pop up. We've already seen patient navigators and care coaches," Leonard says.
The new types of providers may be less skilled and less educated than the clinicians who provide direct patient care, but they're also less expensive, she adds. This means it will be more economical to hire a less skilled person to do jobs that don't need the expertise of a licensed clinician.
"Case managers are likely to be the people who will have oversight over the less expensive health care worker. The National Quality Forum has suggested in their work, which was published for public comment, that the care coordination team has to be led and overseen by a licensed health care professional. I don't think the public is going to let that idea die. They want to feel protected in what they are doing," she says.
(For more information contact: B.K. Kizziar, RN-BC, CCM, CLP, owner, B.K. & Associates, e-mail: BKANDASSOC@att.net; Margaret Leonard, MS, RN-B, C, FNP, senior vice president for clinical services, Hudson Health Plan, e-mail: mleonard@HudsonHealthplan.org; Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder, Mullahy & Associates, e-mail: firstname.lastname@example.org; Nancy Skinner, RN, CCM, consultant, Riverside HealthCare Consulting, e-mail: email@example.com.)