Achieving Healthcare Delivery Goals Through Patient-Centered Case Management

Patient-centered case management is more than a phrase that is gaining popularity across health and human services. It is a philosophy whose time has come. As the name implies, patient-centered case management puts the emphasis squarely on the patient and his/her support system or family. As a new term that is gaining usage, the patient-centered approach implies that selection and coordination of services is done from the patient’s perspective and in consideration of the patient’s circumstances. It encompasses addressing primary care and psychosocial needs, managing chronic conditions, timely access to care, improving patient-physician relationships, and providing patient education, while recognizing that value is added by controlling healthcare costs.

One of the first references to patient-centered case management was in a 2007 groundbreaking study by Carnegie Mellon and Blue Shield, which demonstrated that a patient-centered focus in case management and care coordination improved quality, reduced admissions, and decreased costs. More recently, an emerging model of care delivery is the patient-centered medical home. What this shows is an increased acceptance of the patient-centered approach from acute care to ambulatory care, and even in other venues such as workers’ compensation.

As this article will illustrate, the patients who can best benefit from patient-centered case management are those with multiple co-morbidities. These cases require more healthcare resources. Thus, they benefit from advocacy and coordination of care, as well extensive patient education to manage their medical conditions over longer periods of time. As the healthcare reform debate continues, the benefits of patient-centered case management should be brought into the discussion.

The patient-centered approach contrasts with third-party provider or payer-centered case management that emerged in the 1980s as a way to reduce utilization of services. The third-party approach used utilization review, which was called case management in its early development, as a means to control costs by limiting patient access to care. This model proved to be of little value to the overall management of patient care. There were no financial incentives for third-party providers and payers to be held accountable for patient outcomes. Positive outcomes were only measured in terms of benefit to the payer. Little if any effort went into promoting an integrated healthcare delivery system.

As the practice has evolved, case management has morphed from largely utilization review into a more sophisticated model as seen in the patient-centered approach. Patient-centered case management is aligned with case managers’ primary obligation to act as advocates, providing access to the right care and treatment resources that patients need when they need them, while acting as stewards of scarce and costly treatment resources. In a complex and fragmented healthcare system, case management is the one constant in providing individualized care and treatment. As the Commission for Case Manager Certification (CCMC) Code of Professional Conduct for Case Managers states, advocacy is a process that “promotes beneficence, justice and autonomy for clients. Advocacy especially aims to foster the client’s independence. It also involves educating clients about their rights, healthcare and human services, resources, and benefits, while facilitating appropriate and informed decision making, which includes considerations for the client’s values, beliefs and interests.” (CCMC, 2010)

 

Patient-Centered Case Management in Action

Research has shown that patient-centered case management is a model of care that is best positioned to serve patients with complex chronic medical care needs that require additional strategies to achieve cost-effective, positive outcomes. These cases are complex or “expensive,” in terms of cost and consumption of care and treatment resources, and therefore most likely to benefit from a patient-centered model. Examples of individuals who would benefit most are those with degenerative neurological disorders or late-stage cancers.

Evidence of the effectiveness of patient-centered case management was established in the Carnegie Mellon and Blue Shield study, which found that patient-centered case management improved healthcare quality, reduced hospital admissions, and decreased overall care costs. The study focused on 756 patients with a life-limiting diagnosis with multiple co-morbid conditions. Seventy-five percent of the patients in the study were oncology patients in California covered by a large commercial HMO.

In the study, published in the American Journal of Managed Care, half of the patients were assigned to receive traditional provider-centered case management services and utilization management. The other half of patients received patient-centered case management with support such as a registered nurse (RN) case manager, RN team manager, and a physician assigned to the case. Patient-centered case management services included end-of-life case management to educate patients and coordinate a pain management care plan.

Roughly half (358) of the 756 patients received patient-centered management. More oncology patients who received patient-centered case management elected to discontinue chemotherapy or radiation compared to those who received “usual case management.” The patient-centered case management patients also had reductions in inpatient diagnoses indicative of uncoordinated care: nausea (-44 percent), anemia (-33 percent), and dehydration (-17 percent). Further, those who received patient-centered case management had utilization reductions such as: inpatient admissions (-38 percent), inpatient hospital days (-36 percent), and emergency room visits (-30 percent). These individuals also experienced increases in home care days (22 percent) and hospice days (62 percent), which are more cost-effective than hospital-based care.

The study showed that patient-centered case management resulted in a 38 percent decrease in hospital admissions and a reduction in costs of $18,000 per patient, while also achieving a high patient satisfaction rating. In addition to a 26 percent reduction in overall costs, patient lives were not shortened (26 percent of patient-centered case management decedents versus 28 percent for usual case management). The conclusion drawn by the study authors was that “intensive patient-centered [case] management can sharply reduce utilization and costs over usual management without shortening life.”

Although the study focused on the needs of patients with life-limiting diagnoses and end-of-life and pain management issues, the benefit of patient-centered case management can be extrapolated to a wider population of patients including individuals with chronic illnesses. According to the Agency for Healthcare Research and Quality, more than 90 million Americans have chronic illnesses, and about 20 million children have at least one chronic health condition. Medical care costs associated with chronic illness account for more than 75 percent of the nation’s $1.4 trillion in annual healthcare costs.

Further, the projected rise in the population of elderly adults in the United States is also expected to increase the need to manage the incidence of chronic medical conditions. The current healthcare system cannot support the expected increase in medical costs that will be required to maintain and support a rising chronically ill population. The patient-centered case management model has demonstrated that investing in patient-focused care reduces medical costs and produces positive patient outcomes for those individuals with chronic medical conditions.

 

Patient-Centered Medical Home

Recently, the patient-centered approach has gained attention as part of the discussion around two emerging concepts: medical homes and accountable care organizations (ACOs). In the era of healthcare reform, these two approaches are being explored as ways to improve specific outcomes such as the efficiency, efficacy, quality, and cost-effectiveness of care delivery. What stands out about these organizations is how care delivery is carried out; specifically it is performed by a team of professionals led by a primary care physician and held accountable for the care provided. Engaging the patient and the family in the process is seen as integral to the success of the program. Indeed, the patient-centeredness of these models points to the importance of keeping the primary focus on the specific needs of the patients in order to achieve desired outcomes such as reduced hospitalizations and to better manage chronic conditions.

The patient-centered medical home concept is gaining more visibility across the healthcare system, with proponents emphasizing the ability to broaden access to primary care and to enhance care coordination. According to the Patient-Centered Primary Care Collaborative, the patient-centered medical home affirms that clinicians should take personal responsibility and accountability for the ongoing care of patients, be accessible to patients with expanded hours and open scheduling, conduct consultations through email and telephone, utilize the latest health information technology and evidence-based medical approaches, and maintain updated electronic health records, conduct regular checks to identify health problems and initiate treatment to prevent costly emergency procedures, advise patients on preventative care based on environmental and genetic risks, help patients improve lifestyle decisions, and coordinate care to make sure procedures are relevant and necessary and performed efficiently.

Accountable care organizations (ACOs) build on the patient-centered medical home. According to the NCQA definition, ACOs are provider-based organizations that take accountability for both the quality and costs of healthcare for a defined Medicare population. ACOs include partnerships or joint venture arrangements between hospitals and physicians and other professionals. An ACO emphasizes care coordination and integration with a goal of simplifying the process for patients, enhancing quality, improving efficiency, and reducing costs.

These new models of care delivery become even more important if and when healthcare reform policies in the United States are put in place to extend coverage to millions of uninsured Americans, many of whom have co-morbidities and chronic conditions that have not been adequately treated in the past. It is well known that there are gross inequities in the availability and delivery of healthcare services in the United States; those who are poor have the least amount of access. As these individuals access the healthcare system it will most likely be through a medical home, whether outpatient clinic, mental health facility, nursing home, adult day care, or through an ACO or other venue. For those with complex or life-threatening conditions, patient-centered case management will be essential to educating and empowering people to making decisions regarding their own care in accordance with their wishes and circumstances.

No approach, however, is without challenges or flaws. Some of the confounding factors that may be encountered are the patient’s ability and willingness to adhere to physicians’ orders, including medication administration, follow-up appointments, diet, and exercise. Compliance issues influence outcomes and must be controlled to achieve a reasonable cost savings. Without patient cooperation, patient-centered case management can neither meet its goals nor achieve desired outcomes.

Yet the results of patient-centered case management in certain populations such as those with complex cases shows the promise that can be realized as this approach is taken in a broader population. As strides are made to improve quality, efficiency, and efficacy of healthcare delivery in the U.S., patient-centered case management should be employed wherever possible to make the most positive contribution.

 

Dorothy Consonery-Fairnot, MSHA, RN, CCM, CLNC, is Chair of the Commission for Case Manager Certification (CCMC), the first and largest nationally accredited organization that certifies case managers (www.ccmcertification.org). She is also the Southeast Regional Manager and Medical-Legal Product Manager for MedInsights, a subsidiary of Gallagher Bassett Services, Inc. Email: Dorothy_Fairnot@ MedInsights.com