Collaboration in care:
Case management can make a difference

By Teri Treiger, RN-C, MA, CCM, CCP
Case Management Society of America President 2010-2011

The widely recognized Institute of Medicine’s 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century,” proposed a framework for improving health care quality in the United States through the pursuit of six improvement targets: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The IOM report went on to describe primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” Almost 10 years later, this country’s health care system continues to transform in an effort to improve the delivery of quality care. One emerging model of care is the patient-centered medical home, or PCMH.

According to the Joint Principles of the Patient-Centered Medical Home, a PCMH is “a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.” This model continues to gain momentum as regulations associated with the Patient Protection and Affordable Care Act are issued and enacted.

Along with regulation comes the desire to demonstrate compliance, often in the form of accreditation and certification programs. The National Commission of Quality Assurance issued PCMH standards in 2008. Currently, the nonprofit health care accreditation organization URAC is preparing its patient-centered primary care home program. Both offerings call for medical practices that aspire to become accredited to offer care-coordination services to their patients. The concept of care coordination extends beyond current practice and moves toward cross-continuum integration with all participants of the health care system as well as within the patient’s base of support (e.g., family, community-based services). Health care, supported by information technology, is focused upon assuring the patient obtains the right care, at the right time, in the right place, in a manner that is appropriate to their cultural and linguistic needs.

The terms care coordination, care management, and case management appear 20, 22, and 10 times respectively within the ACA. While each term has a unique definition, they have become somewhat interchangeable in general use. The Case Management Society of America defines case management as “a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s health needs through communication and available resources to promote quality cost-effective outcomes.” Not every patient will require high-intensity care coordination, but the individual with complex needs associated with chronic, co-morbid health conditions, such as congestive heart failure in combination with chronic obstructive pulmonary disease, encounters both tremendous challenge and opportunity for improvement in his or her overall health and quality of life.

In his 2008 article, Thomas Bodenheimer, M.D., M.P.H., wrote: “Care must be coordinated among primary care physicians, specialists, diagnostic centers, pharmacies, home care agencies, acute care hospitals, skilled nursing facilities, and emergency departments.” The difficulty of caring for individuals with complex health conditions cannot be understated. Left on their own, patients face seemingly insurmountable obstacles in understanding their health condition and obtaining necessary clinical care across disparate financial and delivery systems while at the same time maintaining current knowledge about their health care coverage and benefit limitations. While working through a rocky health care landscape is difficult for a lay person, it is the specialty of a skilled case manager.

Given the level of complexity of health care infrastructure, there is a tremendous opportunity for clinical practices to leverage the knowledge and experience of case managers as integral members of the patient’s health care team. Case managers come from a variety of educational backgrounds, including nursing and social work. The professional case manager is uniquely positioned to coordinate care and services and is adept at working with patients to understand their health conditions, the importance of adhering to their prescribed plan of care, and providing vital connections to available services and resources.

Practice-based case management has been in place for many years in group practices such as Harvard Pilgrim Health Plan and the Geisinger Health System. The embedded model has case managers seated within the practice and readily available to clinicians. When care coordination is required, the case manager takes on the responsibility of working with the patient to find an acceptable vendor or supplier, reviewing health care benefits for coverage, obtaining authorization of services, and coordinating the delivery of care or equipment in a timely manner. Case managers also monitor service and care to ensure prompt delivery, patient satisfaction, and progress toward desired health outcomes, and report their observations back to the health care team to evaluate efficacy and alter treatment plans as necessary.

It is exciting to see the prospects for case management professionals expanding into the medical home practice structure. As health care makes the transition to the patient-centered medical home model, case managers will meet the needs of both patient and practice in providing ongoing care and support with an end result focused on the improvement of patient care quality.

To learn more about the role case managers can play in improving patient care coordination, consider attending CMSA’s 21st Annual Conference and Expo in San Antonio, June 14 - 17, 2011. As the nation’s leading professional case management association with over 10,000 members, CMSA fosters cross-continuum professional collaboration focused on enhancing the role of case management in advocating for patient wellbeing and improved health outcomes.