As managed care evolves, CM adapts to changes

CMs address patient needs throughout system

The impact of managed care has already reached Affinity Health System in Wisconsin, where case managers had to struggle with the question of whether they should be specialists or generalists and how much direct involvement they should have in dealing with managed care companies.

Jean Russell, vice president of health management with Network Health Plan, says Affinity had a case recently that called into question how to take assignments at her facility. "There’s a lot of emphasis on discharge planning for case managers. Shouldn’t it be the role of the hospital case manager to work with the payer’s case manager on a patient in the community who’s left the hospital? Shouldn’t it be her role to keep that patient at an optimum health care level?" Russell says her vision is for those patients to be assigned the same case manager when they are admitted to the hospital. "I think assignments should be made that way, rather than based on cardiac or orthopedic factors."

"This is an evolutionary period in managed care," says Russell, who works with Mercy Medical Center in Oshkosh and St. Elizabeth Hospital in Appleton, both part of Affinity. "As it evolves, our case management efforts need to evolve with it. In one of our hospitals, for example, we’ve assigned one of the case managers to the emergency department."

She says a part of their vision is that when the acute care section of the hospital is not the appropriate level of care for a patient, they address the patient’s needs at whatever level is most appropriate. "And sometimes that’s right there in the ED. People sometimes go to the emergency department for reasons that are not emergent. Our case manager there triages the people not needing acute emergency care." She says her team sees that move away from the general hospital as leading to a community-based case management program. "We’re hoping to follow up ED cases and really provide the optimum in a seamless system of care."

She says Affinity is working on some population-based programs. A task force at the organization is planning to help seniors by hosting social events at which activities more substantial than socializing take place. "We can present programs that provide legal advice and do mini health assessments," says Russell. "For example, we’ll try to find congestive heart failure patients early and get them to treatment in an ambulatory setting. I see case managers moving toward more roles like those." Affinity also is working on a systemwide diabetes program.

A high-risk pregnancy program called "Baby and Me" will be implemented systemwide by November. "We used case managers from the health plan to manage the high-risk cases, but now I have responsibility for deciding who is going to manage the cases that are not health plan but are within the Affinity Health System population," Russell says. "There will always be a need for individual case managers, but there’s an evolution to merge their functions with quality and utilization functions."

For more information, contact Jean Russell, vice president, health management, Affinity Health System, Network Health Plan, Appleton, WI. Telephone: (920) 720-1602. E-mail: jrussell@ networkhealth.com.