Discharge Planning Advisor

Enhance care by making CM part of Medicare

Value of case managers yet to be recognized’

Even with their dependence on health maintenance organizations (HMOs), many of the nation’s elderly suffer from a lack of coordinated care, are often confused about their treatment — including proper use of medications — and frequently end up in the hospital for lack of proper preventive measures.

At the same time, notes case management consultant Cathy Kauffman-Nearhoof, RN, BSN, CCM, CMCN, CLNC, many seniors don’t have extra financial resources to put toward self-pay health initiatives.

With that in mind, Kauffman-Nearhoof, owner of Integrist Health Care Consulting in Duncansville, PA, says she has been focusing her efforts since spring 2003 on getting government programs such as Medicaid and Medicare to cover the cost of case management.

"My proposal is that, if the government would add case management as a component of Medicare and Medicaid — saying that if [recipients] get certain government health care benefits, they agree to case management as a mechanism to manage care and costs — everybody wins," she adds.

Case management, Kauffman-Nearhoof contends, is one answer to managing the skyrocketing costs of health care as baby boomers enter a system with insufficient nurses to care for them. "With a holistic approach to assessment, including team planning, collaboration, intervention, and provider communication, optimal outcomes become the primary focus."

Unlike physicians and dietitians, she notes, case managers cannot bill Medicare and Medicaid for their professional services.

In letters to legislators, Kauffman-Nearhoof argues that case managers should be permitted to practice their profession "proactively rather than reactively.

"We propose and request your support to introduce new legislation that would permit experienced and qualified licensed nurses and certified case managers to provide our professional services, independently if we choose and on the home front, and recognize our value by permitting us to be reimbursed for our professional services by Medicare, Medicaid, and other insurers," she writes. Complicating her efforts, Kauffman-Nearhoof notes wryly, is the fact that "organizing nurses is like herding cats.

"Case managers are mostly nurses, and nurses are impossible to organize," she adds. "They have no idea of the clout they would have politically if they organized and advocated as a professional entity to be reckoned with, and often perceive their work as a job and not a profession."

Adding to the challenge, Kauffman-Nearhoof says, many nurses — most of whom are women — are busy people raising families and taking care of aging parents. "When they go home from work, they don’t want to do another [work-related] thing."

"And if they are working for a hospital," she adds, "most of their needs are met. The facility takes care of their benefits and their financial, educational, and social needs. [Lobbying efforts] are generally left to those of us working independently, and we’re a small group compared to the entire population of nurses."

For more information about the lobbying effort, including a template for the letter Kauffman-Nearhoof intends to send to legislators, contact: