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Keep business focus but keep in mind your influence on people
As the emphasis has shifted toward the business aspects of health care, some case managers also have shifted their focus from the positive influence they have on patients lives to the impact of case management on the bottom line, Peter Moran, RN, C, BSN, MS, CCM, asserts.
Recently elected the 17th president of the Case Management Society of America (CMSA), Moran, an emergency room case manager at Massachusetts General Hospital, wants to shift the focus so it is more balanced between the business case for case managers and how case managers help patients and families in difficult and stressful situations.
Moran is the first staff case manager and the first hospital-based case manager to serve as president of CMSA, an international organization with headquarters in Little Rock, AR, representing more than 10,000 members who work in the case management field.
"When I started out as a case manager, case managers were focused on the patients and how we could help them. Over time, that has been considered a nicety but there has been more of an emphasis on return on investment. As we struggle about how to justify case management, more case managers are thinking with their business hats on," he says.
Case managers still have to make a case for the business aspects of case management but they need to start emphasizing how they impact patients as well as family members, he adds.
"I understand about business and return on investment, but I never forget in my daily practice that my reason for being a case manager is that I believe I can impact outcomes and improve lives," Moran says.
When case management directors talk to the CFO about instituting new programs, they need to be able to show the return on investment that case management initiatives bring about but they should balance it with anecdotal information about how case managers positively impact patient-centered care, he adds.
"It's not all about the money. We can have a good return on investment by meeting patients' needs. I never speak before any audience without giving a patient story. As we tell the stories of how we have helped patients, it brings us back to reality that although we are in a business, we are also dealing with people," he says.
Case managers 'have arrived'
Today's case managers face challenges but also new opportunities in the rapidly changing health care environment, Moran says. "Health care is truly at a pivotal point in history and case managers are uniquely positioned to positively impact the health care system and the clients we serve. Case managers are no longer the best kept secret in health care. We have arrived and we need to embrace the spotlight and the opportunities presented to us so we can continue to improve the care we give," he says.
As president, Moran plans to reopen the CMSA standards of practice for review and updating.
"Case management is evolving and we need to develop a new paradigm with fewer silos and more collaboration across disciplines. In the past, different disciplines have worked in their own silos but everybody has a vested interest in the patient's outcome. In order for us to make progress, every discipline working at every level of care, must work together," he says.
CMSA has helped organize the National Transition of Care Coalition and is collaborating with other health care stakeholders on the panel to develop ways to eliminate some of the problems that occur as patients move through the continuum of care.
"The multidisciplinary players at the table — nursing, physicians, pharmacy, case managers — are working with representatives from business coalitions and citizens groups as well as organizations like URAC, The Joint Commission, and the Centers for Medicare & Medicaid Services [CMS]. The various parties are looking to be collaborative in this effort. The coalition is not breaking down into turf wars. We are seeing a problem and how we can address it," he says.
The initiatives created by the coalition will be helpful to case managers as they struggle with providing continuity of care across the various venues of care in the health care system, he adds.
A joint work group from CMSA and the National Association of Social Workers (NASW) has introduced the first draft of a case management caseload calculator as the first step in developing a matrix to determine appropriate case loads for case managers in a variety of settings.
"Caseloads are a problem that every case manager struggles with daily. The Caseload Work Group was created to establish guidelines that case managers and social workers can use to help determine what their caseloads should be. This may not be the final answer but it's a step in the right direction," he says.
The caseload calculator is posted on the CMSA and NASW web sites with a public comment period that ended Sept. 17.
CMSA has another task force looking at the potential for expanding the practice of reimbursing physicians for medication adherence to other disciplines, Moran adds.
"Currently, physicians may get reimbursed for counseling a patient on medication and working on medication adherence with patients but other providers cannot. Many case managers work with patients on medication adherence as part of their care coordination routine. We are looking at ways to get that reimbursed," he says.
CMSA already has published case management adherence guidelines that case managers can follow to help their patients adhere to medication regimens and treatment plans, Moran points out. In addition, the organization has expanded those guidelines and included disease-specific guidelines for diabetes, deep vein thrombosis, and cardiometabolic risk, with several others under development, Moran says. The guidelines are available in English, Spanish, French, and Korean and can be downloaded for free from the CMSA web site.
Adherence 'new buzzword'
"Adherence is a new buzzword and the emphasis on it is going to grow by leaps and bounds," Moran says.
The emphasis on medication adherence and following evidence-based treatment plans gives case managers opportunities to expand the ways they improve patients' lives and at the same time challenges them to obtain new skills, Moran says.
"Medication reconciliation, although it is difficult to achieve within the hospital setting and in provider settings, is one practice that can only improve patient care as it cuts down on mistakes," he says.
New skill sets will be required of case managers in the future, Moran points out.
"We're starting to see it in some programs now. Case managers need to know how to make a health literacy assessment and medication knowledge assessment of patients. They need to know how to assess a patient's readiness to change and need motivational interviewing skills," Moran says.
Case managers across the spectrum of care already are working to motivate people to take responsibility for their own health practices, Moran points out.
"Hospital-based case managers have to address people who are hospitalized over and over for the same condition. On the payer side, there's a financial incentive to help people manage their health," Moran points out.
Community-based physician practices, especially those with a capitation-type model for reimbursement, also have an incentive to get patients to improve adherence to the treatment plan, he adds.
"For patients to follow plans of care based on evidence-based best practices can only serve to improve their health and the health of the nation. Facilitating the flow of information will serve to decrease unnecessary and expensive duplicate services and expedite a return to health," he says.
Moran challenges case managers to raise the bar and refuse to settle for the status quo and to find balance between the art and the business of case management; between their work and families; and between their work and finding the time to take care of themselves, he adds.
"It's an exciting time to be a case manager with many challenges and opportunities before us. We can both hide our head in the sand and try to maintain the status quo or we can move forward, embrace change, and grow and evolve to the next level," he says.