Expect a community care focus in case management’s future
Technology, data sharing also will play likely roles
Hospital case management can expect significant changes to its landscape in the near future. The incorporation of new technologies into health care and a growing focus on community case management are two trends that hospitals can’t afford to ignore as health care prepares to greet the new millennium.
"It is an exciting time to be a case manager. The field is growing and developing," says Diane L. Huber, PhD, RN, FAAN, CNAA, associate professor at the University of Iowa College of Nursing in Iowa City. According to Huber and other industry leaders, several trends have begun to emerge that soon may be standard practice in hospital case management:
1. The inclusion of community care management.
"Case managers provide a critical client-oriented coordination of care that benefits both the . . . individual client’s needs and the need to control high costs," Huber says.
As a newly elected member of the Commission for Case Manager Certification (CCMC) in Rolling Meadows, IL, she says case management will help improve health care in the United States by "going beyond an episode of care. [Case managers] work across service environments; they interact among providers on behalf of clients . . . and they address multifaceted needs for care in a system marked by fragmentation."
Some case managers already are addressing that fragmentation, says John Borg, RN, MS, senior vice president at Clinical and Community Services of the Valley Health System in Winchester, VA. "I think case management is moving to the continuum, and though it [has been] very acute-care oriented, length of stay and cost savings for the inpatient acute are pretty much maxed out. The only [way] we have to cut costs now is to translate [case management] and put it on the continuum. . . . Case management is going into the community," he asserts.
Linking acute-care patients to external services such as skilled nursing facilities, nursing homes, and home health agencies may be something that’s more typically associated with payer-based case managers, but experts point out that hospitals need to consider the positive effect that community-based care can have on their outcomes, as well.
"From a cost-benefit standpoint, it’s clearly more effective than readmission," says Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Canton, MI. More importantly, there’s an increased emphasis on care. The bottom line, she insists, must be making the patient safe, healthy, and independent.
Taking it to the streets
Community case management provides a bridge from the hospital stay or emergency room visit to the patient’s daily life. In some cases, patients may have a skilled nursing need; in others, simple instructions for good self-care are the only real prescription.
Homa-Lowry has seen that develop in hospital maternity wards. Case managers will initiate care education during a new mom’s hospital stay, teaching her about infant care as well as her own physical and emotional needs after the birth, then the case manager will go into the home to follow up that care education. "We need more of that in diabetes management, asthma, and other disease management."
Possible obstacles to community care
Hospital acute care case management extends into the community when hospitals assume financial risk for a selected population or have a business imperative for managing patients across the continuum. In that case, hospitals will definitely want to measure the effectiveness of community case management, says Larry Strassner, MS, RN, consultant with CapGemini Ernst & Young in Philadelphia.
But as in the maternity example, case managers have found that their personalized community care is proving effective, "in terms of return visits to the hospital, the pediatrician, or the OB/GYN," Homa-Lowry explains.
Reimbursement a possible obstacle
Experts warn of another issue that might work against the push to integrate acute and community care: reimbursement. Hospital case management may be moving into the community, but limits on Medicare reimbursement to skilled nursing facilities, nursing homes, and home health agencies could cause problems, Strassner says.
"We are seeing a trend in Medicare HMO plans discontinuing services and home health agencies closing due to budget constraints as a result of Medicare reimbursement. . . . That is creating placement and post-acute care coordination issues. Case management is experiencing a level of pushback’ from the community and the need to keep the patient in the acute care setting," he says. "Within the next three years, we’re not going to be able to move patients out of the hospital as quickly as we have before."
"The only place we can continue to cut costs now is to transition [to] community case management and integrate it with the home care program so it functions on the health continuum," Borg says. "Case management needs to be outside the acute care walls to continue its effectiveness." (For more on community case management, see Hospital Case Management, July 2000.)
2. The integration of acute care with other services through technology.
"Case management needs to be enhanced by additional clinical documentation systems that tie together acute care, outpatient, physician, and clinic visit information," Borg says.
The ability to transfer and store information for multiple users will get easier as Internet and intranet systems continue to take hold, he explains. While this is a very expensive venture right now, "the Web is going to make it more accessible." Independent physicians’ offices and home health agencies will start using the affordable technology available, and case managers can benefit from all of that knowledge.
Without the technology, Borg says, "We spend an average of an hour to two hours on every discharged managed patient, calling two or three physicians to make sure they know what medications [the patient] is on." Sharing information on the Internet could change that.
The technology also could help tackle another severe problem in the scope of the nation’s health care: medication mismanagement, especially of the growing elderly population. "Case management is the key to medication compliance and [avoiding] medication errors," Borg says. "Many of our [elderly patients] are on nine to 15 drugs a day and need constant, correct supervision. Physicians generally don’t develop relationships like that."
Of course, regulatory factors will be important, especially in light of the Health Insurance Portability and Accountability Act rules. Those rules include case management under covered "atypical" services, making it subject to the privacy standards set forth by the federal government. In practice, that means case managers will have to be diligent in following their facilities’ guidelines regarding the privacy of patient information transmitted electronically. But the benefits of technical integration far outweigh the risks.
3. Case management as the facilitator of better communication among disciplines within a facility.
Homa-Lowry laments the lack of communication in many care facilities today. She says you sometimes can tell by "looking at the medical record that the patient’s care hasn’t been integrated very well." Case managers should be the ones who maintain good relationships among the different departments "because they have a better opportunity and ability to step back and look at the big picture." Instead of one person worried about risk, one about reimbursement, one about supplies, and one about discharge, "there must be consistency and communication," she says.
Corporate compliance, for example, is a big issue. Are case managers getting the back-end data [about the analysis between medications, supplies, and billing]?" she asks. "They clearly should be," so that they can measure against it.
Huber agrees. "With case management, value is placed on finding needed resources . . . and using professional expertise to communicate and problem solve. In this way, the management of complex conditions is enhanced and accelerated." Both the individual and the health care system at large benefit from good communication, with shorter stays and better-focused care plans.
Other issues loom in case management’s future as well. Credentialing will become even more needed and respected, says Strassner. More importantly, case managers will need to continue to demonstrate that they have the clinical depth and experience that make them valued health care professionals.
For more information, contact:
John Borg, RN, MS, Senior Vice President, Clinical and Community Services, Valley Health System, Winchester, VA. Telephone: (540) 536-8030.
Judy Homa-Lowry, RN, MS, CPHQ, President, Homa-Lowry Healthcare Consulting, Canton, MI. Telephone: (734) 459-9333.
Diane Huber, PhD, RN, FAAN, CNAA, Associate Professor, College of Nursing, The University of Iowa, Iowa City. Telephone: (319) 335-7122.
Larry Strassner, MS, RN, Manager of Healthcare Consulting, CapGemini Ernst & Young, Philadelphia. Telephone: (215) 448-5625.
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