Case management role is likely to expand under health care reform

Efficiency, quality of care, smooth transitions will gain in importance

As health care reform rolls out, hospitals will be under more pressure to deliver care faster and more efficiently with better outcomes, coordinating care while patients are still in the hospital, and ensuring a smooth transition to the next level of care. And that's where case managers can make a difference, experts say.

"Hospitals are going to have to be more efficient in the way they deliver care and at the same time improve the quality of care. As they struggle with these challenges, case management should become an important part of the process. Case managers can help optimize care process outcomes, including financial outcomes, quality of care, and the patient experience," says Cary D. Gutbezahl, MD, president of Compass Clinical Consulting, with headquarters in Cincinnati.

With health care reform and the influx of newly insured patients who seek care, it will be more important than ever for case managers to manage the care process so that patients receive the right level of care at the right time, adds James R. Proctor, a director with KPMG LLP, the U.S. audit, tax, and advisory firm.

Proctor envisions a more important role for case managers as the provisions of the Patient Protection and Affordable Care Act go into effect over the next few years.

"Case managers must make sure their hospitals deliver efficient care at the right level and in a manner that produces good outcomes. The earlier case managers become involved with patient care coordination and shepherd them through the care process, the better the quality of care and outcomes will become," he says.

Because health care reform aims to improve access to care, reduce costs, and improve quality and outcomes, case management is right on the frontline, adds Catherine M. Mullahy, RN, BS, CRRN, CCM, president of Mullahy & Associates LLC, a Huntington, NY, case management consulting firm.

"If case managers felt like they have been in the line of fire with lack of resources and having to do more with less, just wait until health care reform starts unfolding," she adds.

The health care reform legislation passed by Congress in March simply accelerates the transformation that already has been taking place in the health care industry, Proctor points out.

"The key drivers of health care reform are about decreasing costs, improving access, and improving quality. That hasn't changed. The priorities have just changed in some respects," he says.

Under health care reform, the Centers for Medicare & Medicaid Services (CMS) and commercial payers will continue to tighten up reimbursement, especially for hospital-acquired conditions and readmissions within 30 days, Gutbezahl predicts.

Health care reform also will place additional pressures on commercial payers, which is likely to make them less flexible and more likely to deny payment for care unless previously authorized, Proctor adds.

Hospitals already are experiencing financial pressure, and they will face more as health care reform kicks in, Proctor adds.

Because financial reimbursement is going to change, there will be more pressure to get patients out of the hospital quickly and to make sure that they have a discharge plan that helps them avoid being readmitted, Mullahy says.

Many in health care predict that when the number of people with insurance coverage increases, physician offices and hospitals will be flooded with an overabundance of new patients.

Hospitals can expect an influx of patients in their emergency departments, due in part to the shortage of primary care physicians, Gutbezahl says.

"With more people insured, the demand for services will go up and the supply of outpatient providers will be limited. People who can't get an appointment with a physician will go to the doctor's office of last resort — the emergency department," he says.

In addition, many people who haven't had insurance don't have a lot of experience in using the health care system, and they may think that the emergency department is where they go for treatment, Gutbezahl says.

With so many emergency departments already operating at capacity today, even the slightest uptick will be problematic, Proctor adds.

"The continued trends in utilization are not sustainable if a flood of newly insured [patients] enter the marketplace. Hospitals will have to deliver care faster and better, both from an operational and a financial standpoint," Proctor says.

Hospitals must be prepared to expedite care for patients who present to the emergency department, regardless of whether they are admitted as inpatients, receive observation services, or are referred to other resources in the community, Gutbezahl says.

"I can see a greater role for case managers in the emergency department. Hospitals are going to have to do a better job of gatekeeping and triaging patients by applying admission criteria immediately to determine if [patients] meet medical necessity for an inpatient admission, rather than doing so after the fact," he says.

Hospitals can't afford to admit patients and then change their admission status after the case manager sees them the next day, Gutbezahl adds. They are going to need to assess patients quickly to determine if they qualify for inpatient admission or need observation services before they are placed in a bed, he says.

Moving patients through the system as quickly and safely as possible will be more important than ever, he adds.

Once patients are admitted, it is important for case managers to work closely with social workers to find community services early in the hospital stay for patients who will need them after discharge, he adds.

"Case managers can have a huge impact on length of stay by lining up the community resources people need after discharge," Gutbezahl says.

With the volume of patients increasing, the pressure on case managers is likely to increase, Proctor says.

This means that hospitals will need to make the highest and best use of the case managers' professional skills and training and offload some of the tasks that don't require a nursing degree, he adds.

In many hospitals, the case management role is not really concerned with managing the care of the patients, and that has to change, Proctor says.

"In many hospitals, the case managers are required to focus largely on retroactive utilization management and retrospective review versus assisting patients in navigating the oftentimes complex health care delivery system. I see opportunities to give case managers enhanced responsibilities in many hospitals," he says.

For instance, at many hospitals, case managers spend several hours a day on the telephone with managed care companies. The same tasks could be handled by a paraprofessional unless a clinician-to-clinician discussion is necessary, he adds.

"Tasks like documentation and assembling data for the Recovery Audit Contractors are an important function for hospitals, but putting case managers in charge of these tasks is not making the best use of their time. They may know what is needed to do the job. They can sort through the medical records, but that's not managing patient care," Mullahy points out.

The more tasks that case managers are responsible for, the fewer patients they can manage, Gutbezahl points out.

He recommends that case managers be limited to the case management role, rather than taking on documentation and other tasks that require a lot of time.

"When case managers are responsible for documentation, they spend more time on chart review and tracking down physicians to improve documentation. None of this relates to getting a patient treated and discharged in a timely manner. It creates a distraction and prevents case managers from fulfilling their roles," he says.

Make sure your hospital takes advantage of the case managers' clinical expertise and that they spend their time efficiently, allowing them to get more involved with patient care earlier in the patient stay, Proctor advises.

Educate hospital administration that it's impossible to manage the care of complex patients and take on all the other tasks case managers often are given "since they're already in the chart," Mullahy says.

"Case managers need to advocate for themselves and help the administration understand that they can't wear all these hats and do an effective job," she adds.

Often physicians don't see case managers as clinicians who work with patients. Instead, case managers are perceived as documentation specialists, she adds.

"Handling paperwork is not why we went to school. I don't think you need highly trained, compassionate people to perform documentation assurance. This can be done by coding specialists or people with medical terminology expertise," Mullahy says.

Advocate for administrative support or case management assistants who can take over some of the clerical duties such as paperwork and telephoning, Mullahy says.

"Nurses should be handling activities that only a nurse can do. Physicians often have physician assistants to take over some of their work. Case managers need a similar type of assistant," she says.

To be effective, case managers should see patients with a medical admission every day to evaluate them for medical necessity and to determine what they need to move quickly and safely through the continuum, Gutbezahl says.

"Many hospitals have protocols for patients on the surgical unit. With a medical admission, the direction of care is less certain, and someone needs to facilitate inpatient care every day. It requires discipline and a commitment," he says.

Gutbezahl recommends that case managers on medical-surgical units should have limited focus and a caseload of 20 to 25 patients in order to maximize their efforts at care coordination and patient throughput.

Case management directors should concentrate on their role to drive the care management process and make sure it works effectively and efficiency, Gutbezahl advises.

"This means that case management managers can't spend all their time going to meetings. They should pick their meetings carefully and limit them to those where they can have an effect," he says.

For instance, a case management director should attend a throughput meeting but possibly skip a general standing meeting for infection control.

As their role in care coordination increases, case managers are going to need more resources to handle the extra responsibilities, but they may be challenged to prove it to the hospital management, Mullahy says.

"Perception is everything. If an organization doesn't perceive case management as having value, it won't give them the resources they need," she says.

To get more staff, which will be needed to move the influx of patients in and out of the hospital, case managers must be able to demonstrate the value of what they are doing, Gutbezahl says.

"It's all about metrics. If case management departments don't have good metrics, they're an expense to the hospital. When case managers can demonstrate how much money their efforts are saving, the hospital administration isn't interested in cutting their program," he says.

[For more information contact:

Cary D. Gutbezahl, MD, president, Compass Clinical Consulting, e-mail:;

Catherine M. Mullahy, RN, BS, CRRN, CCM, president, Mullahy & Associates, e-mail:, James Proctor, director, KPMG, LLP, e-mail:]