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For Your Business or Department
Developing a Business Plan
Pricing the Market
Looking at the Competition
Networking and the Professional Community
The Business Community
Generating New Business
Hiring Additional Staff
Defining Success
Business Websites
CHAPTER 8
Home Care Case Management, Long-Term Care, and Healthcare Reform
Consumer Demand and Ambivalence
The Case Manager as a Pivotal Link
Cases in Profile
Ongoing Support at Home
Importance of Feedback and Communication
Payment Concerns
Tools to Help You Assess the Quality of Care You Are Receiving
Informing the Client
Level of Involvement
Importance of Ongoing Involvement
Changes in Long-Term Cases
Negotiating for Long-Term Care
Employing all Possible Resources
Long-Term Care of the Elderly
Implications of Long-Term Care for the Family
Implications of a Long-Term Case for the Case Manager
From Acute Care to Home Care: A Case History
CHAPTER 9
Pediatric Case Management
Challenges Facing Pediatric Case Managers
Achieving Quality Improvements in Pediatric Case Management
Medicaid and the Pediatric Patient
Levels of Pediatric Case Management
Children’s Hospitals
Immunizations
Caring for Children with Mental Health Problems
Benefits of Case Management
CHAPTER 10
Workers’ Compensation Case Management Overview
Benefits
Costs and Occurrence
Workers’ Compensation Case Management and Rehabilitation Management
Impact of the Affordable Care Act
Veterans’ Return to the Workforce
Mediating Workers’ Compensation Claims
Other Issues in Workers’ Compensation Case Management
Workers’ Compensation and Implications for Case Managers
Value-Based Health Care: Workers’ Compensation and Case Management
PART IV THE CASE MANAGEMENT PROFESSIONAL
CHAPTER 11
Legal Responsibilities of the Case Management Professional Malpractice
Other Legal Issues: Patient’s Bill of Rights and Patient Confidentiality
Medical Records, Electronic Health Records, and HITECH
The Right to Know versus the Need to Know
Disclosure Issues
Adequate Information
Contracts and Letters of Agreement
Legal Issues in Case Management
U.S. Legislation Relevant to Case Management
CHAPTER 12
Ethical Responsibilities of the Case Management Professional
Patient Rights and Case Manager Responsibilities
Ethics and Medical Errors
Codes of Ethical Conduct
Objectivity and Common Sense
Look to Your Resources
CHAPTER 13
Evidence-Based Practice for Case Managers: Data-Driven Decision Making
What Exactly Is Evidence-Based Practice?
Evidence-Based Practice for Case Managers
The Evidence
Case Management: Specific Evidence-Based Resources
Applying Evidence-Based Case Management
Conclusion
CHAPTER 14
Case Manager Credentialing and Organizational Accreditation
Certified Case Manager (CCM)
The CCM Exam
Before CCM, to the Wide Array of Credentials Now Available
Certified Professional in Healthcare Quality (CPHQ)
Concerns and Questions
CHAPTER 15
Reimbursement Resources and Challenges
Insurance Providers and Administrators
Basic Insurance and Administrative Company Players
Administrative and Customized Services
Employers and Case Managers Respond to Costs
CHAPTER 16
Healthcare Reimbursement: Private Sector or Employer Sector
Auto Insurance
Health Benefit Insurance: Employer-Sponsored or Private
Indemnity Plans
Group Medical Plans: HMOs, PPOs, and POS Plans
Disability Insurance Plans: Short Term and Long Term
Consumer-Driven Healthcare Plans
Diagnosis-Specific Benefits
Traditional Insurance versus Self-Funded Plans
Stop-Loss Insurance Plans
Viatical Settlements
Nontraditional Policies
Riders to Life Insurance Policies
Coordination of Benefits
CHAPTER 17
Healthcare Reimbursement: Public Sector
New Directions in Public Sector Case Management
Funding Sources for Public Sector Health Benefits
Economic Impact and Government Response
A Case Manager in the Public Sector
CMS Population Groups Challenge Managed Care Industry and Providers
Challenges for Case Managers
Remaining Complications
Nonmedical Challenges Influence Outcomes
Military (Active and Veteran) Case Management
Conclusion
CHAPTER 18
Working Effectively with Claims Departments: Case Managers in Consulting Roles
Claims Department Structure and Operations
Computerization
Claims Issues
Indicators for Case Management
The Case Manager as Consultant
Tracking Claims by Group
Tracking Claims by Individual Claims Histories
Moving into the Consultant Role
PART VI LEADERSHIP AND MANAGEMENT: MACROSYSTEMS
CHAPTER 19
Outcomes Management with Analysis of Financial and Quality
Assurance Reporting
Financial and Quality Assurance Reporting
Dollars and Health Care
Negotiating Skills
Nuances between Negotiating with Providers and Payers
Negotiating in a Managed Care Environment
Documenting Negotiated Arrangements
Cost–Benefit Analysis Reports
Cost–Benefit Analysis Summaries
Quality Assurance Programs
Explaining Difficult Situations
Feedback from Patients
Sharing Questionnaire Results
CHAPTER 20
New Strategies for Leading a Case Management Department: Today and into the Future
What Is the Difference between Leadership and Management, and Does It Matter?
Redefining Case Management
Evaluating a Case Management Department
Business Considerations for Your Case Management Department
Recruiting and Hiring Additional Staff
The Search for Case Managers, and the Retention of Valued Ones
Training and Continuing Education
Staffing
Outcomes
Positioned for Success
CHAPTER 21
Predictive Modeling and Case Stratification
What Is Predictive Modeling?
Implications for Case Management Practice
Conclusion
CHAPTER 22
New Characteristics of Today’s Healthcare Systems
Continuation of Hospital Consolidations
Continued Development of New Care Models
Growing Shortage of Physicians
CHAPTER 23
The Case Manager’s Role in the Era of Value-Based Health Care
Measuring Clinical Outcomes to Demonstrate a Provider’s
Efficient Care
Hospitals Entering New Risk Arrangements with Payers
The Role of Case Managers in Value-Based Models
Healthcare Price Transparency
CHAPTER 24
New Case Management and Healthcare Provider Approaches for Managing the High-Risk, High-Cost Patient
Identifying the Superutilizer Patient
Predictive Modeling
Population Health Management
Healthcare Informatics
Informatics and Transitions of Care for Complex, Chronically Ill Patients
Complex Care Management Models of Care
Medicaid Health Homes
PART VII FOCUS ON CURRENT CHALLENGES AND EMERGING TRENDS
CHAPTER 25
The Aging Population, Medical Advancements, and New Case Management Considerations
Our Graying Population
New Challenges
New Opportunities
Care Management
Additional Resources
CHAPTER 26
Dying in America
A Personal Story
Death Is Not an Option
Examining Your Own Feelings
Addressing the Issue of Death
DNR Orders
Pain Management
Hospice Care
Palliative Care
CMSA’S 2002 Dying in America Survey
Cultural Diversity and End-of-Life Issues
Call for Improvements in End-of-Life Care
Right-to-Die Legislation
Overprescribing of Opioids
Medical Marijuana
Conclusion
Endnote Resources
CHAPTER 27
Medication Management: A Case Management Call for Action
Medication Use among the Elderly
Problems Associated with Multiple Medication Use
In the News
Tips on Managing Polypharmacy
Medication Reconciliation
Medication Nonadherence: The Opposite Problem
Adherence Fact
The 10 Most-Prescribed Drugs
The 10 Drugs on Which We Are Spending the Most Money
Comprehensive Medication Management: Beyond Adherence and Reconciliation
What Is Comprehensive Medication Management, and Why Does It Matter?
Pharmaceutical Industry Update
When Drugs Become Deadly
Marketing Drugs Directly to Consumers
Staying Abreast of Pharmaceuticals
Conclusion
CHAPTER 28
Pain Management
Types of Pain
Assessment of Pain
The Pain Treatment Management Spectrum
Evidence-Based Practice Implications
Implications for Case Managers
Case Management Resources
CHAPTER 29
Our Nation’s Multiculturalism and Challenges to Case Managers
Changing Demographics
Acculturation and Assimilation
Implications and Opportunities for Case Managers
Language and Communication Barriers Are Problematic
The Differences Matter
Family Values
Communication Considerations
Where You Are From Does Matter
Guidance and Standards
Cultural Competency: Defining It, Achieving It
The Role of Culture in Health Care
Case Managers Make a Difference
Developing Cultural Competency
A 12-Step Program
Conclusion
CHAPTER 30
Health Literacy and Adherence Issues
Increased Need for Health Literacy
Economic Impact of Health Literacy
Literacy and Health Literacy
Day-to-Day
Considerations
Health Literacy Manifestations
The Case Manager’s Vital Role
Conclusion
Resources
CHAPTER 31
Obesity: The New Epidemic
Obesity: A Simple Definition, a Complex Problem
Metrics to Determine Obesity
Etiology
Treatment Overview
Going Forward
CHAPTER 32
Behavioral Health with Primary Care: An Integrated Model of Care
Prevalence, Cost, and Impact
Treatment Alternatives: Established and Innovative
Chronic Disease and Depression
Chronic Mental Illness and Serious Mental Illness
Partnering Successfully with Behavioral Health Professionals
Behavioral Health Disease Management Programs
Opportunities for Case Managers
Resources
CHAPTER 33
Healthcare Technology and Trends: Implications for Case Managers
Text Messaging
Mobile Health
Medical Advances and High-Cost Services
Remote Patient Monitoring
Telemedicine and Telehealth
Clinical and Business Analytics
The Macro View
And for Case Managers . . .
New Considerations Regarding EHRs
Data Breaches and Potential Ramifications for Case Managers
Ethical and Legal Issues Challenging Telehealth and Telemedicine
Open-Access Scheduling
CHAPTER 34
Transformative Healthcare Approaches for the Millennial Generation
Digital Natives
Health Behaviors of Millennials
Millennials’ Expectations of Healthcare Providers
Ramifications for Case Managers
Concierge Medicine
CHAPTER 35
The Affordable Care Act of 2010: Implications for Case Managers
Individual Mandate and Increased Coverage
Implications for Behavioral Health
Implications for Health Literacy
Implications for Patients with Disabilities
New Developments
Implications for Case Management Practice
Index
Through her many consulting and speaking engagements, Catherine is in touch with case managers from New Orleans to Chicago and Los Angeles to New York City, in practice settings from hospitals to ACOs. Continuously broadening her scope, Catherine is consistently expanding her knowledge base through perpetual reading, scanning, and the exchange of information. In her roles as contributing editor for publications such as Hospital Case Management and Case Management Advisor, and writer/contributor to Care Management and Professional Case Management, she frequently connects with editors keeping her finger on the pulse of the ever-changing world of case management. Through consulting engagements, she serves side by side with CEOs, CFOs, and medical and case management directors and case managers, helping to create and launch case management divisions, departments, and programs, reimagining, deploying, and aligning programs more completely with the CMSA Standards of Practice. She has taught case management in her “nuts and bolts,” “how-to” awardwinning course, Best in Class Case Management, as well as in customized seminars and workshops for pediatric hospitals, the Veterans Health Administration, and the Indian Health Service. She has worked with both small organizations and very large ones with complex structures and politics, always focusing on helping to accomplish their organizational goals.
Catherine’s basic knowledge of case management is as deep as it is broad. Her professional career spans multiple facets of the field. She owned and operated her own case management company for over 20 years. She headed a case management division for a Fortune 500 company. Additionally, she was a member of the group that initiated the Commission for Case Manager Certification (CCMC) credential, and ultimately was named its chair. In this pivotal role, she and her committee drafted the first Code of Ethics for CCMC. As President of the Case Management Society of America (CMSA National), she worked to establish the Ethics Statement for Case Managers. To this day, Catherine continues to contribute to those organizations. Her current business, Mullahy & Associates, has been named an official educational partner to the CCMC, for which she delivers the CCM Certification Workshop: Best in Class Case Management, helping thousands become new CCMs.
Her business is a well-respected educational resource where information and learning tools can be found on the company’s website, www.mullahyassociates.com. They include DVDs, an online learning management system, quarterly newsletters, and workbooks with all slides on flash drives to assist case managers in maximizing their potential.
No one in case management today has her unique combination of leadership
experience and the ability to connect with all individuals across the continuum of health care, from healthcare CEOs to physicians, case management supervisors, veteran and new case managers, and other professionals. It is her passion and dedication to case management and its mission, and to case managers and their commitment to their patients that sustains this deep body of her life’s work. It is also what has fueled her continuing attention to revise and expand The Case Manager’s Handbook. This Sixth Edition has again been significantly updated. Previous chapters have been enhanced with the latest data and information and six completely new chapters have been added. They include chapters on:
Pediatric Case Management
Workers’ Compensation Case Management Overview
New Characteristics of Today’s Healthcare Systems
The Case Manager’s Role in the Era of Value-Based Health Care
New Case Management and Healthcare Provider Approaches for Managing the High-Risk, High-Cost Patient
Transformative Healthcare Approaches for the Millennial Generation
As is her style, you can almost her speaking as you read the book. Catherine is the consummate storyteller. In that way, she transforms the language of difficult abstract concepts into scenes that the reader and listener can comprehend and convert into their own meaningful action. Her contagious passion for case management is embedded in every page of the book, just as it is in her seminars, workshops, and keynote presentations.
For the past 10 years, as a Vice President with Mullahy & Associates, I have had the pleasure of working side by side with Catherine. As colleagues and friends, we have worked together in case management for over 40 years. Her vision for all that case management can be is contagious and shared with every word she speaks and writes. It is amazing to watch her transform a room of silent, often skeptical nurses, social workers, physicians, and therapists into a group of enthusiastic, networking professionals filled with hope, energy, and renewed passion for case management. I believe you, too, will be both informed and inspired as you read and refer to this sixth edition of The Case Manager’s Handbook.
Best wishes for every success in case management, Jeanne Boling, MSN, RN, CCM
American cultural anthropologist Margaret Mead is believed to have said, “Never doubt that a few caring people can change the world. For, indeed, that’s all who ever have.” When compared to other groups, case managers are certainly fewer in number, but from our very earliest days, we have been making a major impact on the healthcare system, in general, but most importantly, on the patients who need our intervention most. Despite the many medical advancements we have witnessed, there remains a profound problem with our system of care wherein access to care and the right care still elude many, and where care is available, it does not automatically guarantee the best patient outcome or experience, nor the cost effectiveness of care. The provider and payer systems surrounding health care are more complex than ever, and as a blogger recently commented, “it’s easier to order a pizza than select a health plan.”
So here we all are in the era of healthcare reform and navigating our healthcare system just keeps getting more and more challenging. For case managers, these challenges come with many new responsibilities and new opportunities. It is the mission of this sixth edition of The Case Manager’s Handbook to provide case managers and others aligned with our profession the information, insights and encouragement needed to be the instruments of positive change for all patients, but especially those for whom case management was most intended: patients with comorbidities or complex health problems that require our skills and advocacy most.
From the very beginning, my goal for this book’s readers was to help each individual realize that each one of us can make a difference, and that the process of case management does not have to be as complex as some would have us believe. At its best and purest, case management is connecting an individual in need to someone who cares enough to make a difference. While we now have many sophisticated tools, software platforms, predictive modeling, and seemingly enough evidence-based practice guidelines for all the diseases known to humankind, why then are so many individuals still vulnerable and at risk within our systems? To be sure, we have to acknowledge that our role in case management has changed, and not always for the better. As more rules, regulations, guidelines and protocols consume more of our time, we wonder, what about our patients? Our professional education and experience may make it possible for us to do more and, as the size of this edition illustrates, the current environment has in fact introduced many new models of health care, treatment modalities, pharmaceutical and biological advances, technological changes, evolving legislation and regulatory matters, new financial and reimbursement issues, community resources, and so much more. What we really need to remember, however, is that patients are at the very heart of what is truly unique and special about case management. Our standards of practice and codes of conduct should be the framework that guides us and throughout the text, we
are reminded of their importance.
As predicted, the Affordable Care Act (ACA) has impacted all systems, all employers (public and private), and all providers . . . including case managers. While the need for case managers has never been greater, and the opportunities continue to expand in all practice settings, there remains a lack of formal preparation for those entering this role as well as an available resource for those seeking to improve their skills and competency. This book fulfills all of those needs and more! Additionally, with the ACA directly and indirectly resulting in an increased demand for the certification of case management professionals, it has become more important than ever that case managers continually expand their knowledge and professional credentials.
This edition of The Case Manager’s Handbook, as with the preceding editions, focuses the major portion of its text on the “nuts and bolts” of the case manager’s role and responsibilities. Because the core components, essential activities, and knowledge domains as defined by the Commission for Case Manager Certification (CCMC) are an integral part of the “nuts and bolts” of case management, this text also has been used successfully by individuals to prepare for the certification exam. As with so much in health care today, there has been an expansion of practice settings and models of care and in a direct response to these changes, readers will also find discussion of the approaches and considerations that can be applied in these newer areas and which are essential to their continuing professional development.
The emphasis on value-based health care, new technologies, the growing ranks and effects on health care of the millennials, as well as new approaches and challenges in managing high-risk, high-cost patients are just a few of the timely new topics for which new chapters were prepared in this edition. Also receiving some additional focus are those practitioners in pediatric case management, workers’ compensation, and those embarking on a role as a manager of a case management department or one as an independent case manager.
I have always held that within each case manager there is a beating heart. When each of us made the decision to become a case manager, we did so from the heart with compassion for our patients and the conviction that we could make a difference. It is my hope that new and returning readers will find not only practical information to utilize in their day-to-day work, but perhaps inspiration, knowledge, confidence, and a belief that we as case managers can, and do, make a difference . . . one patient at a time!
Acknowledgements
This sixth edition of The Case Manager’s Handbook has truly been a work in progress. From the very first edition in 1995 (!) through this current one, 21 years later, case management has progressed and evolved considerably. Similarly, this book has advanced in parallel with case management’s expanded role, recognition, and practice settings. At the same time, it has continued to be the “go-to” book for case managers in all phases of their careers for those just entering this still evolving profession, as well as the most experienced practitioners. It also remains a valuable resource for other healthcare professionals, providers, managed care organizations, insurers, government agencies, and many others involved in health care. The size and scope of this kind of book are evidence of the breadth and capacity of case management and its far-reaching implications.
The contents of The Case Manager’s Handbook, the updated information and brand new subject matter, are the culmination of many years of experience, cumulative knowledge, and efforts of not just one individual. Thankfully, the publisher of this edition, Jones & Bartlett Learning, has been a long-time supporter of what I have tried to accomplish with each edition. My publisher has an amazing team of professionals who provide their unique talents and support throughout a very long process. Special thanks to Teresa Reilly, Jeanne Hansen, Carolyn Pershouse, and Wes DeShano as the manuscript was edited; to Lauren Vaughn and the creative graphics team for the beautiful cover design and keeping the book on deadline; Katie Hennessy for marketing support; and Linda McGarvey, who provides ongoing sales assistance throughout each year. I’m certain that there are others behind the scenes who have been involved as well, and my appreciation is also extended to them.
For many of the years of my involvement in case management, I was fortunate to have gained experience and insight from many. They include the patients and families with whom I worked as a field case manager; and my clients as the owner of a national case management company, Options Unlimited. Then, upon the sale of Options Unlimited in 2003 to Matria (now Alere), and the start of my current educational and training firm, Mullahy & Associations, LLC (M&A), I have had the privilege of serving many as consultants and educators for both private and public sector entities, as well as individuals, nurse case managers, and social workers, from all practice settings across the continuum of care. All of these experiences have been so valuable and continue to be as I share the knowledge I’ve acquired over these years along with that obtained from the many colleagues who have shared their expertise so kindly, either through ongoing personal relationships or their contributions in case management publications and educational presentations at workshops and conferences around the country. The network of case management professionals is an incredibly generous one, and I
encourage others to reach out to this network when facing a challenging situation, and also to share successes and, of course, to mentor new case managers.
As I contemplated this Sixth Edition, there remained a good bit of uncertainty in our country regarding the future of the Affordable Care Act (ACA). The ACA, with all of its still-moving parts, remains a strong focus in the presidential election process. It has been a frequent topic in the 2016 presidential debates, editorial columns, and conversations across America’s kitchens and corporate boardrooms. I wondered how I would be able to create something that would stand the test of time to remain relevant and provide meaningful guidance, support, and encouragement in the midst of such change. Fortunately, I have been blessed with a few very special members of the “M&A Team”: Jeanne Boling, Donna Autuori, and Deborah Jensen. Jeannie has been a lifelong collaborator and friend as we strive to stay ahead of so much that is going on in health care and case management and to communicate the key messages in a way that makes the information accessible and meaningful not only for case managers, but for patients and their families as well. Jeannie’s amazing abilities and contributions are too extensive to describe here; however, as we continue on this journey, I am eternally grateful that she’s been such an incredible part of all of it!
I’ve often said that before we move forward, it’s also valuable to look back. Many years ago (probably more than any of us would like to recall), Deborah and Donna worked for the same public relations company. I worked with both of them then, then individually on various projects, and now have been able to come together for still new endeavors . . . what a blessing to have these three talented ladies working with me! While each of these three women has her own very special talents and gifts, together we have been able to accomplish so much and I never would have been able to embark upon still yet another edition without their assistance. Through research, collaborative writing, editing, and the endless attention to details (an admitted shortcoming of mine), I was blessed by their encouragement, support, humor, and “hands-on” involvement throughout what is always a longer process than anticipated.
As one might imagine, trying to stay on top of all of the cutting-edge information that’s available at the click of a mouse is incredibly challenging. Trying to recognize not only what will serve us well now, but into the future, can truly be overwhelming. The challenge with this edition, as with the previous ones, was to maintain a strong focus on the core process of case management: the “Best in Case Management” skills and knowledge that are so necessary and have served us so well over these many years, while also incorporating relevant, new information so that case managers, both the beginners and the experienced, can be prepared with the strategies they will need for the emerging models of care.
Relationships with CCMC (Patrice Sminkey, CEO) and CMSA (Cheri Lattimer, CEO) are also valued and my appreciation is also extended to them for their help in facilitating the use of the various portions of the Case Management Body of Knowledge (CMBOK), Code of Professional Conduct, and Standards of Practice. In addition, the
editors of Professional Case Management, Care Management, Hospital Case Manager, and Case Management Advisor have provided me with ongoing opportunities to contribute, share, and learn, and I appreciate their steady support and strong work.
Over the years I have also worked with Ted Howard at SoftCentrix, Inc., and Britt Loyd and his team at Web International, who have been invaluable in helping me package and market Mullahy & Associates educational programs. Their creativity, insight, and guidance are greatly valued.
Of course, while professional and business relationships are valued, it’s the personal and family ones that matter most. To my husband, John, who through 49 years of marriage has been my loving supporter and a continuing believer in the work that I do and enjoy, thanks for your patience and understanding. Since the last edition of this book, I’ve said good-bye to a much loved family member and welcomed another one. My husband’s mom, Mary, passed away recently at the age of 94 at home surrounded by her family, just the way she chose. She was a nurse and a wonderful role model to me as I tried to balance professional and family life as she was able to do. She will be missed. As for that newest member of our family, my sixth grandson, Daniel (still no little girls, and I’m enjoying every minute with these guys), joined his brothers Matt, Brendan, and Ryan and his cousins, Declan and Eamon. To my children, Michael and Aileen and their spouses, Pam and Neal, thanks to you all as well for understanding the times I’ve been away, and especially for all the time that was spent on this book.
We recognize that patients remain at the center of what we hope to accomplish in case management, and a few individuals have demonstrated for me just what it’s like to be a patient in today’s convoluted and complex system. To Sharon, Anne, and Melissa, you have been courageous, gracious, and incredible inspirations to me as you faced your own healthcare challenges and as you continued to fight your way back to recovery. This edition is dedicated to you and other patients for whom we can make a difference. For all patients out there, take comfort in knowing that within every case manager lies beating a heart of deep compassion and concern for you.
THE CASE MANAGER’S ROLE
Case managers are not claims police. Ensuring cost-effective treatment does not mean that case managers are overrated number crunchers who review treatment alternatives simply to find the cheapest scenario. Case managers are coordinators, facilitators, impartial advocates, and educators. Their roles are as varied as the sites where they are employed and the job titles that designated their position in the past.
A case manager in an acute-care facility may have been called a discharge planner a few years ago. In behavioral health facilities, the program coordinator or coordinator of patient services may now carry the title of case manager. Transition care manager, health advocate, health navigator, professional patient advocate, and guided care nurse are just a few of the still-evolving titles. Regrettably, there are now so many titles for those providing these services that it not only has contributed to confusion by its recipients, but it also might decrease the recognition and influence case managers have in the future.
Case managers in hospitals, rehabilitation facilities, nursing homes, long-term care and assisted living settings, home health agencies, and infusion care companies are in the provider sector of health services and may include nurses and social workers. More and more, we are seeing case managers embedded in primary care practices as well, contributing to a decrease in avoidable hospital admissions. They may oversee treatment while a patient is in a particular facility or receives a certain type of service, such as infusion therapy, but not be involved with that same patient’s care when the patient moves on to a different center or care program. Depending on the employer, a case manager may never make a home visit or manage care outside of a particular facility.
In the payer sector, both public and private, case managers may work through thirdparty administrators (TPAs), self-administered programs, health maintenance organizations (HMOs), preferred provider organizations (PPOs), point-of-service (POS) plans, military programs, or major insurance carriers. In these settings, case managers identify and track all hospital admissions and other events in which there is a likelihood of costly or high-exposure conditions. Although the employer emphasis may seem to be on reducing overall costs, these case managers are also dedicated to assisting employees and their dependents in the utilization of services.
Because of financial organizational structure and administrative overhead, many organizations do not elect to maintain an in-house case management department or staff. This, coupled with the direct-to-consumer trend, is behind the growing and diverse opportunities for independent case managers. Those with strong expertise in neonatology, oncology, elder care, or organ transplants may find heightened demand for their services. One such source is stress-ridden baby boomers who call on independent case managers on behalf of their aging parents.
Independent case managers are outside both the medical care provider and the
claims-payer systems. All case managers are charged with the responsibility to make totally objective assessments and to coordinate a program of care. With no vested interest in the companies selected to provide this care or services, independent case managers can be impartial advocates for their clients and may have an advantage in exercising out-of-the-box thinking and solutions.
The focal point of case management in all its roles is to empower patients, giving them and their families access to a greater understanding of their disability or disease, a larger voice in the delivery of their care, and more personalized attention to their particular needs. Obtaining data on the particulars of each patient’s case, case managers enable patients and their families to make informed decisions. Through their role as advocates, they help patients deal with the complexities of the healthcare system.
CASE MANAGEMENT IS NOT EQUIVALENT TO MANAGED CARE
Managed care and case management are not interchangeable concepts. Managed care is a system of cost-containment programs; case management is a process. As a global term, managed care consists of the systems and mechanisms utilized to control, direct, and approve access to the wide range of services and costs within a healthcare delivery system. Case management can be one of those mechanisms; it is one component in the managed care strategy.
Based on the use of cost-containment programs that include guidelines and criteria for healthcare delivery, managed care organizations (MCOs) incorporate a wide variety of options. These may include pharmacy benefits management (PBM), POS plans, consumer-driven plans, HMOs, PPOs, direct contracts (in which an employer contracts directly with a hospital or other healthcare facility), bill audits, utilization review, preadmission authorization, concurrent review, retrospective review, second surgical opinions (SSOs), independent medical exams (IMEs), disease management, and case management. Whereas managed care programs strive to involve all potential users of healthcare services, case management focuses on certain individuals the 3 to 5 percent of the patient population responsible for 60 to 70 percent of the expenditures in any health plan.4
Case management is a highly individualized process that aims to identify the most atrisk, vulnerable, or care- and cost-intensive patients; assess treatment options and opportunities to coordinate care; design treatment programs to improve quality and efficacy of care; control costs; and manage patient care to ensure the optimum outcome. Concentrating, for the most part, on catastrophic or chronic cases, case managers are called on to consult for diagnoses such as head injury, multiple trauma, cancer, AIDS, organ transplant, cardiovascular and respiratory disease, stroke, burns, spinal cord injury, premature infants, diabetes, and high-risk pregnancy.
According to the 2014 Towers Watson/National Business Group on Health
“Employer Survey on Purchasing Value in Health Care,” employers’ costs are continuing to rise as healthcare costs outpace inflation. At the time of the survey, employer costs were expected to reach $9,560 per employee, up 4.4 percent from 2013. At the same time, the employees’ share rose nearly 7 percent (expected to be $2,975 per employee) from a year ago, as more companies continue to shift some of the burden of healthcare costs to employees.5 Other surveys report similar findings.
In its 2013 survey of 2,842 employer-sponsored health plans, Mercer Health & Benefits found that case management was the leading cost-containment strategy among large-employer plans (more than 500 employees), with 82 percent of these companies utilizing it.6 Although these surveys certainly underscore the increase in costs over the past several years, the future poses even more concern as employers address the cost implications post-ACA legislation. The 2013 Mercer survey cited a few of the more significant concerns: the requirement to extend benefits to employees who work more than 30 hours per week and the resulting wild card number of new enrollees in their healthcare plans.7 Mercer’s 2015 “Health Care Reform Five Years In” survey of nearly 600 employers answered one of those unknowns: the average percentage of full-time and part-time employees enrolled in employer-sponsored health plans remained virtually unchanged between 2014 and 2015.8 As employer organizations continue to grapple with these unknowns, most assuredly a bigger focus will be on cost-containment strategies and, hopefully, a brighter spotlight on case management.
The trend toward greater use of case management is not new. In its 1996 Executive Opinion Poll (which introduced a new survey design and methodology), Business & Health asked respondents to name the management techniques applied by their healthcare plans from a list including case management, utilization review, disease management, demand management, pharmacoeconomics, and outcomes research. Outcomes published in “Business & Health Executive Opinion Poll 1996” showed case management leading the other categories as the management technique most used by healthcare plans of large and small companies combined. In a note that should have been a wake-up call to chief executive officers (CEOs), even as it warmed the hearts of TPAs and insurers nationwide, the report mentioned that a substantial portion of respondents did not know whether a particular technique was utilized by their healthcare plan. This reinforced my concern (and continued amazement) that the majority of employers (those who ultimately pay for employees’ healthcare coverage) do not know how that money, that resource, is being managed.
In 2005, URAC (originally incorporated under the name Utilization Review Accreditation Commission, shortened to URAC) conducted a national survey of more than 282 companies regarding trends and issues in medical management. Participants included HMOs, PPOs, stand-alone medical management companies, insurance carriers, and others. The study researched national trends and issues in medical management, and the article “Converging Pathways: A Journey Towards Quality Case
Management” reported that more and more companies were employing a combination of utilization management, disease management, and case management.9
Since the passage of the ACA, employers have become increasingly more keen to manage their healthcare dollars and more aware that certified case managers (CCMs) are effective in helping to accomplish this. According to the Commission for Case Manager Certification’s (CCMC) 2014 Role and Function Study, a greater percentage of employers 40.2 percent now require that the case managers they hire be certified, a 14.7 percent increase from 2009.10 Additionally, other findings from that study will continue to shine a spotlight on case management. There are new regulations and payment codes (Current Procedural Terminology, or CPT) that specifically authorize reimbursement for care coordination, care management, and transition of care activities all within the scope of case management. And, as might be expected with this recognition and reimbursement (pay for performance), there will be an even greater demand for case managers to be able to measure the value and report the outcomes. The success, or lack thereof, of case management may not only result in a reward, but in the case of an avoidable readmission it may result in a penalty for the organization. Of interest as well, ethics, legal, and practice standards were elevated to increased importance as knowledge required of case managers, likely attesting to the complexity of case management today.11
Case managers have long expressed that the benefits of combining case management, utilization review/utilization management, precertification, and newer concepts in health care, such as disease management and wellness promotion, can be achieved when provided in a coordinated system. This integrated provision of strategically designed services can achieve the best outcomes for patients and limit employer and payer risks. Now it seems that this type of system is becoming a reality.
The positive piece that all case managers can embrace is that, within this comprehensive study, case management is perceived as a distinct role and function that is best applied in a coordinated program with utilization management, disease management, discharge planning, and social work. Still, this collaborative model can be improved upon, and more information about case management needs to be communicated.
MEDICAL CREDENTIALS AND EXPERTISE
Agreed-upon credentials and criteria for what makes a good case manager and the level of preparation required to handle the usual responsibilities have long been established as part of the development of the CCM and other case management credentials. Predictably, the criteria caused an outcry from some individuals who claim to offer case management but discovered they are worlds apart from case management practitioners who are eligible for certification. For example, there are individuals currently working
as case managers who have no more experience than 1 year in a hospital and a weekendobtained certificate in case management. Case management as a profession demands critical thinking skills, in-depth clinical knowledge, and extensive, diversified experience within the healthcare delivery system. It is an advanced practice, and, as such, it requires a high level of knowledge and competency.
Today’s case managers come from diverse educational and clinical settings, many with broader backgrounds than a strict hospital environment. Generally, they are nurses, social workers, or rehabilitation counselors, and a number of them have had experience administering workers’ compensation and disability cases involving catastrophic injury. Far beyond helping an individual recuperate and return to work, case managers address health and wellness within disease management and wellness programs, as well as the needs of those already experiencing costly medical conditions and their complications. They assist in everything from tertiary neonatal cases, premature babies, and healthy baby programs to geriatric cases, stroke victims, and living with diabetes. There is a need for broad clinical knowledge and standards of care for less complicated conditions, and on to kidney failure and amputations, which is causing subtle shifts among case management practitioners.
Social welfare caseworkers, involved with programs like Medicare, originated some elements of case management procedures. They developed and perfected the skills involved in connecting people to their community resources and obtaining financial aid from federal and state agencies. Social workers will undoubtedly continue to make up a substantial portion of case managers. Although considerable supplementary training and experience might be required before they could manage complex medical cases, such as ventilator-dependent babies or an individual requiring infusion services, social workers with medical backgrounds can handle stable cases and provide assistance to our fastgrowing “gray” population. They also play a significant role in behavioral health programs. And combining social workers and RNs in medical case management teams has already proven very effective, enabling speedier identification of solutions to patient problems. As professionals with a different focus, rehabilitation counselors have also become valuable members of such teams, with their emphasis on recuperation and the return to work. The diversity of healthcare professionals (i.e., nurses, social workers, counselors, pharmacists, and others) working collaboratively certainly lends itself to the highly desirable integrated model of case management, which is increasingly sought today in many practice settings.
Because of the medical problem solving and coordination responsibilities inherent in the case management role, the kind of experience and education that nurses possess becomes important. In addition to basic educational preparation associate degree, diploma school, or baccalaureate level life experience counts for a great deal. But case management demands a greater depth and intensity of involvement than traditional nursing, as well as more advanced medical, psychological, and sociological training. Therefore, a case manager’s educational process should be ongoing and, through
continuing education studies or postgraduate work, should be directed toward achieving a master’s degree in a clinical specialty, for example. Because continuing education is not mandated for updated RN certification in many states, a number of practicing case managers neglect their obligation to remain current in their field. Those selecting case management as a career owe it to their patients, their profession, and themselves to read, attend conferences, and sit in on seminars and lectures to broaden their knowledge base. The CCM designation requires case managers to take advantage of continuing education to maintain their credential status, as does the Accredited Case Manager (ACM) from the American Association of Case Managers, the Case Manager Associate (CMC-A) from the American Institute of Outcomes Case Management (AIOCM), the Certified Social Work Case Manager (C-SWCM) designation from the National Association of Social Workers, the Registered Nurse-Board Certified (RN-BC) from American Nurses Credentialing Center, and many others.
Due to the tendency of multiple conditions, sometimes comorbid, in the case management patient population, the kind of clinical experience of greatest value is that of a generalist. Although there are case managers with a single practice area, such as those who specialize in high-risk neonates, head trauma, organ transplants, oncology, or hematology, most case managers should have experience with a variety of age groups, treatment facilities, and medical conditions. The majority of case managers will receive referrals requiring knowledge of a wide spectrum of medical practice specialties, and they will need to acquire a diversified clinical background to meet the challenges. Ideal clinical preparation includes in-depth exposure to medical–surgical treatments, intensive care, critical care, home care, psychology, obstetrics, pediatrics, and neurological care. Case managers must be able to distinguish good care from bad care, understand potential complications, and evaluate alternate treatment options. Working in one hospital unit for 1 year does not provide the range of cases and insight required of a good case manager. Even comprehensive hospital experience alone is insufficient preparation. In most hospitals, equipment and supplies are readily available. Leaving the safety and support systems of the hospital environment, we can appreciate how vulnerable our patients can become when necessary services are fragmented. Further, case management requires self-direction, critical thinking, and independent functioning and judgment, skills honed more readily in nontraditional healthcare settings. Experience in home health care, walk-in clinics, and occupational health nursing can provide a beneficial view of community healthcare options.
Because the work requires financial savvy, a business background is also helpful. Hospital nurses do not have to cost out the care they are administering, but case managers must be financially accountable. If they cannot demonstrate the positive impact of case management to its stakeholders (payers, providers, patients), case managers undermine the value of their industry and, therefore, their future. They need to know, for example, the cost of infusion care treatment so they can question payment on a creatively submitted invoice. Forget that they can help improve employee morale,
help a disabled person get back to work faster to continue a rewarding career, and locate an appropriate facility 10 miles from home rather than 550 miles away for a child with a head injury; if they cannot combine their healing skills with practical business skills, they will lose the opportunity to practice.
Case management work often places individuals in situations in which patients and their families are devastated by health-related problems. Beyond facilitating healthcare decisions on behalf of other human beings, case managers also face the type of intense social–dynamic family issues that never become easy to handle but can be approached with more empathy and grace by practitioners who have become acquainted with the emotions encountered in marriage, divorce, illness, and death. Less experienced practitioners are likely to have difficulty appreciating the significance of such issues. Five or more years of clinical experience helps develop a maturity and depth that makes it easier to relate to patients and understand their emotional state.
Case managers need personal stamina and strength. Most caseloads include tragic cases. Case managers cannot make a terminal illness fade away. They cannot fully empower a patient if the family is too broken to accept the necessary responsibility. Case managers, therefore, need personal resources and support from friends and family to meet the challenges each day will present. A can-do mentality, a ready sense of humor, and the gift of levelheaded self-affirmation to take personal note of small successes every day are among the traits that boost a case manager’s effectiveness.
A DEFINITION OF CASE MANAGEMENT
The CCMC (www.ccmcertification.org) defines case management as follows: “Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client’s health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes.”12
The CMSA (www.cmsa.org) 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.”13
As one can appreciate, the aforementioned definitions, although professional and descriptive of the process, would be a bit overwhelming to patients, their families, and even some of our colleagues in health care. We did not want to create a barrier to the introduction and hopeful acceptance of our intervention, so case managers came together via another organization under the auspices of CMSA: the Case Management Leadership Coalition. After a review of 150 definitions, the organization adopted the following consumer-friendly definition, which was then translated into eight different languages and made available on their website: “Case managers work with people to get
