To find an efficient route to an unfamiliar destination, many of us have emptied the glove compartment of paper maps and instead rely on GPS. And so it used to be for consumers navigating the health-care system. In the past, patients took a direct route: They called their doctors, were seen and, if necessary, referred to a specialist.
So today — as we’re forced to fill out myriad forms, navigate insurers’ elaborate phone systems and often endure long waits for care — it’s easy to get nostalgic about the bygone family doctor.
Of course, no one wants to roll back medical advances. But we do yearn for that single-point-of-contact health-care expert who can provide the right care, when we need it, without unnecessary and expensive detours. In the 2010s, that guiding light will be the primary-care case manager. We are working to make this happen in Maine, to restore a more patient-centric approach.
Graying Caseload, Payer Complexities Create Challenges
With the growing number of people living longer with chronic diseases, management of complex treatment regimens has become a necessity for the provider as well as the consumer. With payment methodologies that challenge even the most sophisticated office staff, many providers have limited their practice based on payer source in order to minimize the number of systems they must navigate. While this may be necessary for their business practice, the situation limits consumer access to care.
Our need for consumer, provider and payer coordination is immediate and we are fortunate to have a model to follow. The model bears many names, such as care coordination or patient navigation, but at its core it is case management.
Today’s case managers are highly skilled in helping both consumers and providers navigate the health-care system and these professionals are joining health-care teams across the country in an effort to deliver care more effectively. While it is not unusual to find case managers in specialty areas, their presence is growing rapidly in primary care, where their impact is dramatic and immediate.
Maine Pilot on Patient-Centered Care Reduces ED Visits
There are studies that support the use of case management in the primary-care setting, most of which reflect the effectiveness of the model in ways that were not initially anticipated. Consider, for example, the
work of Jeffrey Brenner, M.D., in Camden, N.J. Without the benefit of a large team or funding, he identified Camden’s most complex health-care consumers in terms of both health-care needs and cost and then developed strategies to meet those needs. The result of his work is improved outcomes for these individuals and cost savings for the health-care system. What Dr. Brenner did was case management.
Following the model of Dr. Brenner, the state of Maine has embarked on a project related to use of the emergency department. In this pilot at Maine General Medical Center, ED care coordinators collaborated with Medicaid members, primary-care coordinators, ED physicians, primary-care physicians and local social-service agencies. This patient-centered health-care team developed individualized plans of care for 30 members with the highest number of ED visits.
The early data from this project shows a significant decrease in ED visits for this group, which results in savings for the state Medicaid system. The best outcome, however, is the dramatic improvement in the ability of these Medicaid members to comply with their plan of care and manage their chronic diseases. We will be rolling this out to other hospitals in Maine.
Case Managers: A Growing Presence in Primary Care
It is clear from the literature and practice that the future direction of health care is the primary-care model. With the advent of
accountable care organizations and patient-centered medical homes, the need to provide care in partnership with our consumers is clear. While that may sound very basic, the amount of information and number of moving parts required to make that happen is overwhelming, especially to a consumer faced with a health problem.
While case managers help consumers and their families understand the intricacies of the system, they also provide valuable guidance to the health-care team. With their comprehensive knowledge of the system, they provide information related to each consumer’s ability to access resources based on his individual circumstance. Having this knowledge informs the design of a plan that gives top priority to the consumer’s health and his ability to access the system. The result is improved adherence to the plan, which has a direct correlation to outcomes.
The importance of compliance with a health-care regimen, whether designed for prevention, diagnosis, treatment or recovery, is well understood. However, it is the ability of the health-care consumer to understand, agree on and have access to that care which ultimately determines the success of the plan. Case managers as members of the primary-care team are key factors in helping consumers manage chronic illness and avoid hospitalizations, which improves cost-effectiveness. But the most important result is improved outcomes.
Given this evidence and the need for a streamlined system, we cannot afford to ignore this option. Our consumers and our health-care system are dependent upon us to develop a more efficient and effective system. We cannot let them down.
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