In the Phoenix Medical Management newsletter of February 2015, I read with interest about "Moving to 4th Generation Models" (Phoenix Medical Management, 2015). If you have followed Phoenix Medical Management's trajectory over the years, they articulate a good history of the evolution of hospital case management, from the early 1980s to the present. According to Phoenix Medical Management, the second generation of hospital case management models integrated the utilization review (UR) and discharge planning functions, overriding the intent that case management was to be a consistent resource for the patients and the providers to move the patients through the progression of hospital care.
The third generation of hospital case management was used in few hospitals and moved the UR function to a delegated team of UR specialists, with discharge planning returning to the bedside nurse. In those models, case managers partnered with physicians to make sure that the patient received the "right care in the right place at the right time." A fourth generation of case managers contains a caveat; they are going beyond the walls of the hospital, as the "model of care coordination goes across the entire continuum for selected patients" (Phoenix Medical Management, 2015, p. 1). Necessarily, these models are patient-centered, rather than place-centered.
ATTENDING THE Case Management Society of America (CMSA) Conference?
As the Official Journal for Case Management Society of America (CMSA), we strive to bring you meaningful and useful articles to aid and enhance your practice. In celebration of the 25th Annual Case Management Society of America (CMSA) Conference, we are providing you with a unique opportunity. Session #4001 will feature Lynn Muller and Ellen Fink-Samnick, on the topic of "Mandatory Reporting: Ethical Dilemma/Legal Crisis." Each has written an article in line with that presentation in this issue, with a "take-away" decision-making tool. We encourage you to attend the conference and this session and look forward to meeting many of you at the LWW Booth.
What we currently see, however, are care coordinators at various sites within a system. Patients are handed over from a hospital case manager to the care coordinator at the medical home, to the care navigator at the cancer center, to the case coordinator working with the home care agency, skilled nursing facility case managers, rehabilitation case managers, etc., and this creates gaps, multiple hand-offs, and patient dissatisfaction.
In the scenario that "everything old is new again," there is currently growing evidence that coordination by a single resource across the entire continuum works best and generates significant outcome improvements (2015). It was in the mid- to late 1990s when I was doing case management for self-funded plan beneficiaries. Unlike my hospital case management experience, I followed the patients/clients through all levels of care, working with social workers and case managers within the facility or agency that my patient/client resided in. In many ways, it was very rewarding. Instead of following a patient for an episode of care (e.g., a hospital admission), I got to know the Gestalt of the patient's life-even to being invited to subsequent parties, or to funerals.
Like the spoke of a wheel, I helped "teach" the other case managers about the patient, authorized necessary health care, and coordinated the transitions. As the "Alpha" Case Manager, I was one-stop shopping, no matter where the patient resided or who had the "hands-on" job of caring for the individual.
Historically, acute care case managers performed their responsibilities in an episodic manner, focusing on the safe discharge to another level of care. Case managers external to the acute care setting performed their job responsibilities according to their job descriptions. There was essentially no communication between the two except for, perhaps, a brief time during the actual "handing over" of the patient. The fragmentation was almost our undoing; the challenge was finding an efficient method of all case managers working together so the patient/client was not a leaf blowing in the wind.
Almost with history repeating itself (in 2000 and today), I wrote in an early book that, if I thought that the "proliferation of case management models (was) not without problems" (Powell, 2000, p. 13), I was not prepared for today's environment, with various professional levels and titles. In 2015, this is still a valid concern in every level of care, from medical homes to acute care.
In two editions of the book (Powell, 2000 and Powell & Tahan, 2010), a suggestion for complex integrated systems is that one case manager must be assigned the task of being the central point of contact for select complex patients (the "alpha" case manager). All the other case managers from the agencies or facilities listed earlier continue as the "attending case manager," managing the crises, coordinating all aspects, and assuring the care meets acceptable standards while that patient resides in their respective within their designated walls.
An important issue when this model is used is that everyone is clear on their roles. If this challenge is not attended to, case management will eventually get a reputation as being a cause, rather than the cure, of health care fragmentation, poor quality, and unsafe experiences or medical errors (Powell & Tahan, 2010).
Case managers so long ago were the "answer" to fragmented health care. We must be vigilant that case management, itself, does not add to this fragmentation. We must realize that it is necessary to have "attending" case managers throughout the continuum; we must also consider which patients must have an "alpha" case manager on their team.
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