Discharge Planning Advisor

On CM frontier, defining care model is crucial

Case managers who are in one of the newest frontiers of the profession, the physician practice, may find themselves in an isolated environment with no clear blueprint as to the skill set and resources they’ll need, says Sandra Lowery, RN, BSN, CRRN, CCM, president of the Case Management Society of America (CMSA) in Little Rock, AR.

Many of the professionals in this position, notes Lowery, who also is president of CCMI Associates, a consulting firm in Francestown, NH, come from a hospital or physician-hospital organization background, and may not have the experience that will prepare them for the unique demands of the physician practice.

Capitation typically is the reason case managers find themselves in this setting, she notes. "It’s wherever there is a transfer of financial risk." In some cases, Lowery explains, a health plan allows a provider to manage utilization — this is called "delegation" — while the health plan gives oversight and holds the provider accountable through "report cards" and evaluation.

Such case managers are often in the position of trying to avoid the need for hospitalization and of making sure an individual’s health needs are met, she says. This can be difficult, Lowery adds, if the case manager doesn’t have a knowledge base of community resources, assessments, and community needs. Additionally, in some cases, she suggests, neither the case manager nor the physician truly knows how to make the best use of the case management function in this setting.

"Most case managers are there because the physician [or physician group] has taken on capitation of some sort, whether just for primary care or more globally," Lowery says. "The physician often thinks the case manager’s primary role is just to manage the utilization of the patients in a hospital setting, which really isn’t going to be the best bang for your buck."

Depending on his or her exposure to and understanding of case management, she adds, "the physician may not know that the gatekeeper model’ — managing utilization of resources through managing access, which isn’t really case management — won’t result in the ultimate desired outcome.

"What we’re seeing in terms of the best outcome is a community-based model, where financial risk is assessed in the community — whether in the physician’s office or in the patient’s home — by using certain triggers," she explains. Those triggers, she says, may be that someone is taking five or more medications, has an inadequate support system, or has had two or more hospitalizations in the past six months.

With this approach, Lowery adds, "the case manager can be much more proactive in achieving a better outcome before the individual reaches a higher intensity and need. This is the ideal model." What’s also unique is that while both may be employed in a physician practice setting, there are typically far more nurses than social workers performing the case management function, she points out. "Whoever does it should have a solid knowledge base of psychosocial needs and resources, as well as medical needs and resources. A high-risk individual needs both."

That usually means the case manager needs more training in one area or the other, she adds. "Physicians may not realize they need these resources. They assume a nurse is a nurse’ and a natural case manager."

For outside support and resources, Lowery says, case managers in physician practices should take advantage of whatever professional associations are available to them.

"I certainly recommend they become part of a professional society, and of course, I recommend CMSA. If there’s a local chapter, they should join that, and minimally they should get connected to a national society." At the least, Lowery notes, these groups can provide standards of practice and information about certification.

Although the CMSA doesn’t have a special interest group as yet for case managers in physician practices, she adds, "I wouldn’t be surprised if that is coming. When individuals join or renew, we get information about where they practice, and we do member surveys."

[Editor’s note: Discharge Planning Advisor would like to hear from case managers working in physician practices. Please share your concerns and experiences by contacting editor Lila Moore at (520) 299-8730 or lilamoore@mindspring.com.]