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Reform offers challenges for CMs
Care coordination mentioned throughout legislation
Once the details are ironed out, health care reform will offer great opportunities for case managers in a variety of settings, says Margaret Leonard, MS, RN-B, C, FNP, senior vice president for clinical services at Hudson Health Plan and outgoing president of the Case Management Society of America (CMSA).
Both the final Patient Protection and Affordable Care Act and the reconciliation bill contain half a dozen new buzzwords and phrases that have long been familiar to case managers, Leonard points out.
Among these are "case management," "care coordination," "transition of care," "disease management," "population management," "medical home," and "hospital readmissions," she adds.
"We are mentioned throughout the bill in so many ways. The people who drafted the health care reform know that care coordination works, but now we have to decide who is able to do care coordination and who can bill for it," she says.
CMSA has opened an office in Washington to ensure that the voices of case managers are being heard on Capitol Hill, Leonard adds.
CMSA representatives are involved in developing a model act for care management based on the standards of practice the organization just revised.
"As the details of health care reform are being developed, CMSA is taking steps to get case managers at the table to help them define case management and design the regulations to make sure that everybody is using the same terms," Leonard says.
Once the government comes up with a payment process for case management services, more opportunities are going to open up for case managers, she adds.
Since there already is a shortage of nurses, case managers, and social workers, initially at least, health care reform is likely to result in more responsibilities for people who already are case managers, points out Catherine M. Mullahy, RN, BS, CRRN, CCM, president of Mullahy & Associates LLC, a Huntington, NY, case management consulting firm.
"Case managers are already concerned that they have too many cases. If more people enter the health care system, it's going to put more of a burden on them," she says.
No matter where they are working, nurse case managers will need another layer of administrative support to handle clerical duties to free them up to take care of tasks that need clinical expertise, Mullahy says.
"We in case management need to do a better job of stratifying patients according to their needs and identifying which people truly need a registered nurse or a social worker as their case manager," she adds.
The team approach for case management and disease management is going to become more important, Mullahy says.
For instance, trained paraprofessionals can perform health coaching if they use a script and call on licensed staff when complex clinical issues arise. In addition, the needs of some patients can be handled by LPNs, Mullahy says.
Mullahy suggests that case management departments perform studies to determine how each case manager spends his or her time to demonstrate the need for additional staff that could increase the efficiency of case managers.
"If the nurses are spending a lot of time on paperwork or on the telephone, those are tasks that can be performed by others. Organizations shouldn't be paying the salary of a nurse to do jobs that an administrative assistant or paraprofessional could do," she says.
The medical home concept has gotten a lot of attention in the talks about revamping the health care system, Leonard points out.
"Here in New York, physicians who receive certification from the NCQA to be a patient-centered medical home are getting as much as an additional $6 per member per month to provide care coordination," she says.
Primary care physicians and their case managers are going to be on the front lines when people who previously did not have insurance seek care, Mullahy says.
"The medical home model and guided care model will help people new to the health care system learn how to access care, but there have to be trained case managers to do so," she says.
Case managers in physician offices will be involved in coordination of care, transition of care, and everything else they're involved in now, but they're likely to be doing it with a larger caseload, Mullahy says.
Preventing hospital readmissions, another hot topic, presents another opportunity for case managers because of their role in transitions in care, Leonard adds.
CMSA convened the National Transitions of Care Coalition, which brings together the major players in the health care arena to develop ways to transition patients safely through the continuum of care.
When people are discharged from the hospital to a post-acute provider, then home with home care services, someone must coordinate their care to make sure that each level of care has the information it needs to provide the services that patients require, Leonard points out.
The primary care physician who sees the patient for follow-up after the hospital discharge also needs to know what happened during the hospital stay. If patients are seeing multiple specialists, someone has to be responsible for ensuring that each clinician knows what the other has determined and prescribed and that the patient is receiving coordinated care.
All of these tasks fall into the case management arena, Leonard points out.
"We already have the training and skills for all of the care coordination that health care reform is going to make essential," she adds.
When health care reform kicks in, physician offices will need more case managers to coordinate care for their complex patients, Mullahy points out.
There will be a need for more case managers to help the influx of beneficiaries on Medicaid learn to navigate the health care system, she adds.
On the payer side, insurance companies are going to need more case managers to ensure that patients receive the most effective and efficient care, Leonard says.
"We went from population disease management and sending out educational information to telephonic case management. Now, payers are developing tools to identify members who benefit from one-on-one case management in an integrated model that combines both behavioral health and medical management. We are moving toward more one-on-one care coordination in the hope that it makes people's lives better and reduces the cost of care," she says.
There also will be opportunities for independent case managers who contract with individuals, attorneys, or insurance companies on a case-by-case basis once there is a payment mechanism in place, Leonard adds.
To avoid losing reimbursement if patients are readmitted, hospitals will have to have care coordinators who work with patients after discharge to make sure patients have follow-up visits with physicians and follow their treatment plan, Leonard says.
She predicts that home care agencies will provide more care coordination to ensure that the primary care physician has information about the patient's home care episodes and vice versa.
"There is a great deal of opportunity for case managers. The medical home model is all about care coordination. Providers are going to have to have someone who is responsible for coordinating with other providers and services to make sure that patient gets everything he or she needs," she says.
But with the opportunity comes the challenge of making sure that people who are called case managers actually are performing the case management role and that people who move into the role have the kind of education they need to do the job, Mullahy adds.
"Employers in every practice setting seem to think that if you're a nurse or social worker, you can be a case manager. We need to make sure that people who are acting as case managers understand the role and all that it entails," she says.
"The stimulus package will have to include additional money for scholarships to train more nurses, but if they finish school, they definitely will have a job," Leonard adds.
The need to education clinicians on care coordination will lead to opportunities for case managers in the academic world where they can share their skills with people in other disciplines who want to become care coordinators, Leonard says.
She predicts that all health care disciplines will receive some basic training in care coordination, case managing, and motivational interviewing.
"The multidisciplinary curriculum will be for pharmacists, social workers, and therapists as well as nurses. We're talking to some schools now about this possibility. Case managers will have the opportunity to be instructors for these programs, or to train the trainers," she says.