With emerging models of care and financial incentives to reduce preventable readmissions, case managers are branching out beyond acute care and showing value by working closely with patients in primary-care and post-acute settings.
According to Patrice Sminkey, RN, CEO of the Commission for Case Manager Certification (CCMC), the emphasis on reducing readmissions is helping get case management “back to the basics by defining case management. It is essentially care coordination around the patient.”
Case managers today are adding new clinical skills and certifications, supporting emerging models of care like global payment contracts and finding employment with payers who have a vested interest in keeping patients healthy and out of the hospital.
There are a variety of models in which case managers are providing services outside the hospital. Some models choose specific chronic diseases for focused assessment and management, whereas others follow an approach that matches specialized case managers with acute and high-risk illnesses and conditions such as cancer and high-risk pregnancy.
Case Management Drives AQC Success
At Northeast Physician Hospital Organization (NEPHO), a management service organization in Salem, Mass., case managers are key to the successful management of 50,000 patients under pay-for-performance and risk contracts on behalf of its owners, New England Community Medical Group and Northeast Health System. Most of the patients are covered by the Alternative Quality Contract
, a new model of insurance created by Blue Cross Blue Shield of Massachusetts.
“The new contract model combines a per-patient global budget with significant performance incentives based on quality measures,” explains Kenneth King, RN, case manager with NEPHO. “The focus is on quality, value and patient outcomes.”
During a pilot program in 2011 to reduce the time between discharge and follow-up appointments, NEPHO case managers were embedded in physician offices where they met on a weekly basis with physicians, nurses, nurse practitioners and medical assistants to discuss care management plans for high-risk patients whose care had been transitioned from hospitals to the physician office. “Many of these physicians didn’t know these patients,” says King. “They were discharged from the hospital, and the physician may not have seen the patient in the last three to four years.”
The case-management presence helped trim the time from discharge to follow-up appointment from 14 to seven days. This achievement helped get physicians to recognize the value of post-acute case management. “They have begun to tell our case managers which patients need case management,” says King. “We’re getting ad hoc referrals.”
Case Management Supports Payer Goals
CareFirst BlueCross Blue Shield of Maryland employees 83 case managers to meet with patients in primary-care and post-acute settings in an effort to reduce readmissions and visits to emergency departments. These professionals are certified in case management and also have specialty certifications in one of the following: high-risk pediatrics, adult and pediatric oncology, palliative care, trauma, rehabilitation, gastroenterology, immune disorders or high-risk pregnancy.
“Our model of post-acute case management began as a general program but has evolved to specialized care,” says Lisa Kraus, RN, vice president of case management. “In post-acute settings, case managers need to have conversations with physicians in specialties like cardiology or oncology. The skill sets are very different from specialty to specialty, and case managers must be well-versed in the medications, disease states and needs of these patients to provide care that keeps patients out of the hospital.”
Currently CareFirst is studying the impact of its post-acute case management program in terms of financial and qualitative impact. “Not every case will have a financial return,” says Kraus, “but the qualitative impact is always positive. We need to demonstrate value to accounts and members. One way to do that is to assess readmission, emergency-department use and length of stay. This requires data and technology — a central documentation system and portal that case managers can access and through which physicians and nurses can see information. Risk-predictability tools are important to help identify the patients for whom case management can provide a benefit.”
Market Analysis Drives Resource Allocation
The key to quantifying post-acute case management and showing measurable results is identifying the complex patients who are at highest risk for readmission. “Which interventions will deliver the highest return on investment?” says Susan Stern, RN, MHA, senior business development executive of URAC. “You need to show value. If post-acute case management is as expensive as a hospital day, there is no savings.”
Understanding populations requires extensive data analysis, says Stern, which includes segmenting claims information and hospital-level data like age, gender, care provider and hospital unit. To do this, health-care leadership needs to invest in innovative tools that can create and analyze data while enabling real-time communication among providers across all settings. The real value of case management in the post-acute setting is achieved when the best health outcomes are reached while duplication of services and redundancies are reduced.
“One region may have a population that has high numbers of patients with AIDS and infectious disease,” says Stern. “In another community where there’s an older population with Medicare patients, maybe heart failure is the disease state that consumes the greatest amount of health-care resources. Post-acute case managers must analyze their populations to understand the care management needs of the community and the neighborhoods they serve.”