The delivery of care that is based upon reducing costs while delivering better outputs is becoming more and more important today. It is often termed 'value based care'. It will be the basis of much future reimbursements models whether from private or government payers. Currently, providers are rewarded bonuses for providing this care, especially in patient-centered medical homes and accounting care organizations. One of the keys to achieving better care at lower costs is the integration and coordination of care among providers. The use of a case manager is an excellent way to achieve these goals.

As stated on the GE Healthcare Camden Group Insights Blog in the article “7 Steps to Achieving Clinical Integration,” “New payment models are making it more important than ever for hospitals to collaborate with doctors. have a growing economic incentive to pool resources, share information, coordinate care and services and cooperate on quality improvement. ” Again, the case is made for effective management among hospitals, providers, and payers.

In a recent interview a former manager at a local hospital was describing to me the goals of case managers at a hospital. At the hospital, a case manager is to manage the discharge of the patient from the hospital so as to prevent readmission for the same cause as the initial admission, as hospitals are penalized for doing so. In an interview with my son, who is an RN and was employed as one for a large, national payer, the goal of a case manager was to minimize the costs of medical care for the patient while providing good care. The goal of the case manager in a physician group is to drive down risk, to improve the quality of care, for the patient. The goals of case managers at all three types of sites is the triple aim-improve population level health, improve patient satisfaction and drive down costs.

How do case managers at each of these three sites reach their goals? What is their scope of work at each site? In a hospital setting one typically coordinates the discharge of a patient. This is a very complex task and is fairly new to many hospitals. One make sure that patients have a follow-up appointment with their primary care physician or specialist within two weeks after discharge or sooner if medically necessary. At discharge she will confirm with the patient the date and time of the follow-up appointment. If there is a problem with getting transportation to the appointment then the she will work to find ways to get the transportation, including working with the insurer if needed.

The hospital case manager will also go over the discharge instructions from the doctor, explaining what the patient needs to do once she is at home. For instance, in the case of knee replacement surgery the manager will explain to the patient what to do to manage pain, what exercise the patient will need to do at home, including visits from a physical therapist if it is covered. He will also discuss the care of the incision site and what to do if an infection develops after discharge. Good ones make sure that the patients understand the instructions and that they are able to accomplish them.

My son as a one for a large insurer worked with patients who had high risk scores as defined by the insurer. Most had comorbidities. These patients were contacted and asked if they wanted to work with a case manager. If they answered yes, then he would contact them and provide insights into their conditions through education. If he discovered that they were not receiving all the medical help that they needed according to standards of care for their condition he would offer to make appointments for them with their doctor. If they could not afford their medications, he would work to find a way to reduce the costs. If they needed transportation to an appointment, he would arrange that for them. In other words, he made sure the patients were getting the level of care needed to effectively manage their conditions so as to prevent progress of conditions to a state that would need more costly care.

Case managers in physician practices often do the work that a physicist wishes he / she had time to do. For instance, a case manager, having access to details of medical records that managers at other sites do not, may track indicators for patients with serious conditions. He / she may track the A1c levels of diabetics. Registries can help with this. If the level is too high the manager will contact the patient to see if further education is needed. Perhaps the manager will have the patient come in for this education and the two will problem solve how to lower the patient's A1c level.

Managers in the clinical setting also make sure that patients have scheduled appointments when necessary. For a diabetic with poor control they may have the patient come in once a month until the indicators improve. The manager will work with the patient to make sure appointments are available and that the patient can make it to the appointment. For instance, the case manager of the orthopedic clinic that my wife uses has set up two post knee replacement appointments.

As one can see, case managers can be of great assistance in helping patients achieve outcomes so that they can lead lives that have high quality. In doing so they will hit the Triple Aim of healthcare.

Case managers can be certified. One body that certifies case managers is the Commission for Case Manager Certification. In order to be certified a case manager generally needs:

  1. A license as an RN, LCSW, Rx or a BA in a social studies field
  2. Experience of 12 to 24 months in a case management field
  3. Pass board exam

Not only do patients benefit from the work of case managers, their employers do also. Hospitals avoid penalties for 'Never Events' such as readmission of a patient within 30 days for a condition that was related to the initial admission. Insurers save money by helping patients get care that is less costly, helping them avoid conditions that require intensive care. Case managers in the physician setting help practices achieve rewards or bonuses offered by payers for providing care that has high value and lower costs.