CARE MANAGEMENT'S CONTRIBUTION TO HEALTH: THE NEXT GENERATION
Many Americans find that the US health care system is a fragmented, confusing, and frustrating maze to navigate. Patients experience miscommunication among their doctors, lack of information transfer from one practice setting to another, and little to no care coordination. Catastrophic, chronically ill, and medically complex patients are at greater risk for medication and medical errors, poor transitions of care from one practitioner or service location to another, noncommunication between medical and behavioral practitioners, duplication of resource use, and high out-of-pocket expenses. In addition to poor coordination at the clinical level, there is also often a significant disconnection among those trying to assist the patient through medical management activities, for example, disease managers, health coaches, case managers, and care coordinators.
As 30 million more Americans access health care services in the coming years, there are questions that all health care professionals need to ask themselves. (1) Are we ready to break the cycle of fragmented care and to embrace a new generation of how health care services are delivered? (2) Are we willing to develop and implement a patient-centered model of care that requires high-performance interdisciplinary care management teams? (3) Will we eliminate communication silos by incorporating accountability for bidirectional communication not only among practitioners but also with patients and their family or caregivers? and (4) Are we ready to realign payment incentives and performance measures to support quality performance for effective clinical outcomes?
For many practitioners, these questions engender anxiety, fear, and frustration. What will this next generation of care look like? How will it change my practice, my income, and my life? For those who magnify the dark side, resistance to change becomes a mantra. Yet, others see the development of a new patient-centered, integrated, and interdisciplinary model of care delivery as a challenge and opportunity to make a difference. This year, the US Congress passed the Patient Protection and Affordable Care Act (PPACA, 2010). Within PPACA are provisions addressing the need for
1. Quality and efficiency of care,
2. A reduction in preventable readmissions,
3. Expediency and communication during care transitions,
4. Care coordination,
5. Unfettered access to care,
6. Medication reconciliation and management,
7. A patient-centered medical home,
8. Chronic care management,
9. Wellness programs,
10. Shared decision making, and
11. Accountability for both the quality and the cost of care.
Care management will play a significant role in addressing every one of these provisions, especially in patients with the greatest health needs. Care managers will set the stage for improving clinical and functional outcomes while reducing costs through their patient-assist activities.
DEFINING CARE MANAGEMENT
The National Council on Aging defines care management as "a component of the community care system. Its process includes assessing a person's functional level and impairment-physical, cognitive, social, emotional-in order to identify what needs and problems are present as well as the individuals current capacity and support-family friends, financial and environment; developing a plan of care that addresses the needs and problems presented and incorporates the services that are needed to enhance the current support system; identifying and arranging for coordinated delivery of those services; monitoring changes in the person's condition and circumstances, and in the provisions of services; and reassessing the person's needs on a regular basis (Powell & Tahan, 2008, P. 11)."
The Case Management Society of America incorporated the term care management in the Case Management Model Act of 2009. The Act defines case management as "a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual and family's comprehensive health needs through communication and available resources to promote quality cost-effective outcomes. Related activities to case management include care coordination, complex condition management, population health management through wellness, disease and chronic care management, and promoting transitions of care services" (Case Management Model Act, 2009). Case management is a subset of care management that targets individuals with health complexity, high health service-use needs, and functional impairment, who account for a disproportionate amount of health system costs. In the past, care management and case management have often been used interchangeably. We suggest that for clarification of terminology, case management should be considered an intervention within care management.
Care management encompasses multiple approaches to intervention that help individuals overcome obstacles to improvement. It includes activities associated with care coordination, disease management, case management, health coaching, quality management, and others (Powell & Tahan, 2008), each of which addresses the needs of targeted populations with variable levels of health complexity and illness severity. Care management activities may assist with medical and behavioral care coordination of services and interventions. These can be provided in a single delivery model, sometimes referred to as integrated care or integrated case management. This patient-centered model provides that consumers make the most informed and rational use of their health care benefits/resources by reducing poorly coordinated interdisciplinary care and improving communication with and among providers.
Utilization management, commonly included under the care management rubric and performed as a part of care management activities, is truly not a care management function. Since utilization management does not include assistance to the individual, but rather establishes that a defined benefit is included in a person's insurance package and that medical necessity is present, it is more appropriately described under the term "benefit management"than under care management. Rather than a "helper"function, it is an adjudication process.
The objective of the various subcategories of care management is to assist patients confused by the complexity of our health system, their health conditions, and/or treatment and prevention needs by helping them enhance the quality of their care, reduce duplication of services, and better address and coordinate physical and mental condition treatment. Through this service to patients, safety should be enhanced, satisfaction improved, and cost reduced, especially in those with health complexity. Since much of health care today is delivered in fragmented silos with noncommunicating information systems, operational processes, workflows, and models of care, implementation of effective care management processes is challenging, but, when accomplished, it can bring improved health at lower cost.
COMPONENTS OF CARE MANAGEMENT
Implementing the next generation of quality care management requires changes and modifications to health care delivery and its support systems, workflows, and processes. For instance, it will be necessary to meet the following requirements:
1. Use multidisciplinary teams, which include medical and mental health personnel and consist of physicians, pharmacists, nurses, social workers, case managers, and other allied health care professionals working in collaboration, to foster health and reduce unnecessary use of health resources.
2. Move from multiple health information technology platforms to an integrated system for benefit and care management activities. This single health information technology system should be interoperable with electronic medical records.
3. Provide support for integrated physical and mental health service delivery with active communication among practitioners.
4. Target patients with health complexity as a core component of any comprehensive care management program, since they have the greatest health needs and utilize the majority of health resources.
5. Focus care management activities so that they incorporate patient, family, caregiver, and provider participation, especially as they relate to adherence and transitions of care.
6. Expand the use of patient portals within medical management and electronic medical record systems, allowing patients to communicate directly with the health care team and to have full access to their medical records.
7. Enhance the training and skills of care managers so that they are comfortable in facilitating care for patients with both medical and mental health conditions, especially in patients with health complexity.
8. Include wellness and prevention as a core feature of any care management activity.
9. Implement patient-centered models of care that utilize motivational interviewing and encourage self-management skills in patents.
10. Move from a biomedical model of care to a customer service model. When care management is unavailable and there is minimal coordination of the care delivered, patients with concurrent medical and mental conditions and those with health complexity often experience suboptimal quality of care, which commonly results in illness complications and adverse events. The PPACA and other health care reform initiatives, such as parity legislation, create an opportunity to significantly improve care delivery by implementing care management capabilities as a part of the change process.
STRATEGIES
To move to the next generation of care management, health care professionals must begin to look at models of care that incorporate multidisciplinary high-performance teams committed to changing the current process and promoting accountability for exchange of information. Essential considerations for implementing care management strategies are as follows:
* Strong collaboration among medical and mental health clinicians, who demonstrate ownership, responsibility, and accountability for total patient care coordination and management.
* Transformational change of operational workflows, processes, and information technology to support care management strategies, especially for patients with health complexity. This involves culture and personal behavior change as well as improvement of interdisciplinary knowledge and skills.
* Implementation of a patient-centered model of engagement, shared decision making, and care planning.
* Alignment of payment incentives and performance measures to clinical outcomes for standard treatment procedures and the enhancement of care through care management.
* Establishment of accountable bidirectional communication among providers, patients, family, and caregivers.
CONCEPTUAL MODEL FOR TRANSITIONS OF CARE
The National Transitions of Care Coalition has developed an example of how communication can change to support bidirectional communication (see the figure later) (Tahan, 2009). It highlights the key elements for effective communication during transitions of care. Professionals implementing care management interventions may wish to use the concepts in building stronger communication between providers, patients, and family caregivers.
Key elements defined for effective communication are as follows:
1. Sender: the health care professional who is accountable for the exchange of key information necessary for ensuring continuity of care.
2. Receiver: the health care professional who is accountable for the receipt of the key information shared by the sender about the patient, usually present at the next level of care.
3. Key information: critical medical, behavioral, and health-related information provided in a timely manner to ensure safe and effective transitions.
4. Act: obligations and tasks that the receiver of the key information executes to maintain continuity of care and services for the patient.
5. Verify: necessary action assumed by the sender to ensure that the key information sent has been appropriately received.
6. Clarify: necessary action assumed by the receiver to ensure that the information was clear and, if concerns were present, the receiver would pose appropriate questions to the sender and obtain relevant answers.
7. Active engagement of the patient and their family caregiver in the communication process.
SUMMARY
The next generation of care management should offer health system stakeholders the innovative ways to provide continuity of care and to reverse high health care expenses associated with the current system's fragmented care approach. It provides an opportunity to improve care processes, increase efficiencies, foster patient safety, augment quality, and reduce cost. To move to this next generation, however, it will require a commitment by practitioners and system administrators to implement creative solutions, which defragment siloed care and better enable improved clinical outcomes at lower cost. Care management is a part of this solution. It offers the opportunity to ensure integrated services to patients; enhanced collaborative clinical teams and technology; and augmented engagement of the patient, their family, and caregivers, and it promotes a functional empowered health care team.
-Cheri Lattimer, BSN, RN
Management Society of America
National Transitions of Care Coalition
Little Rock, Arkansas
-Roger Kathol, MD
Cartesian Solutions, Inc
Burnsville, Minnesota
Departments of Internal Medicine
and Psychiatry
University of Minnesota
Minneapolis
REFERENCES