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Care Management

Care Management vs. Case Management

When patients with multiple chronic health conditions struggle to coordinate and manage their own care, it may be necessary for outside professionals to oversee their healthcare. Care management and case management are two processes that apply to care oversight with a goal of better outcomes. They are not the same, however.

What Is Care Management?

According to the Robert Wood Johnson Foundation (RWJF), care management is “a set of activities intended to improve patient care and reduce the need for medical services by enhancing coordination of care, eliminate duplication, and helping patients and caregivers more effectively manage health conditions. These efforts have demonstrated potential to improve quality and control costs for patients with complex conditions.” One thing to understand when it comes to the financial side of healthcare is that “Care management is relatively costly. Offering care management to patients who are not expected to be high utilizers of hospital, specialty and emergency department care would not reduce costs. Similarly, care management for patients too sick to benefit is ineffective.”

The Effect of Care Management on Costs and Care Quality

Care management is more likely to be focused on outcomes. RWJF tells us that “There is strong research evidence that care management improves quality, but the effect on cost reduction is less consistent. Hospital-to-home care management programs have had the most success in reducing costs. Care management in primary care improves quality, but research indicates it may take time to see results.”

RWJF adds that “Care management within integrated multispecialty groups improves quality, but does not consistently reduce costs. The most effective care management programs are those targeting patients discharged from hospitals. Studies have found that care management programs targeting the hospital-to-home transition have reduced hospital readmissions and lowered costs.”

People, Not Costs are the Main Focus of Care Management

In writing about the promise of care management (CM), The Agency for Healthcare Research and Quality (AHRQ) states, “The development and implementation of CM parallels the rapid transformation of US health care delivery and payment systems over the last decade. CM is a team-based, patient-centered approach designed to address the increasing complexity of care in outpatient settings. It is both a process innovation, with a new model of care and new care services, and a workforce innovation, involving new members of the care team. This issue brief suggests that CM is a key tool for managing the health of populations.”

Important Inputs for Care Management

RWJF also identifies the following essential components of care management:

  • “In-person encounters: Person-to-person encounters, including home visits, are necessary features of effective care management. Care management relying solely on telephone encounters has not shown success.
  • Training and personnel: Programs with specially trained care managers who have a relatively low workload are most successful. Most care managers are registered nurses (RNs) who work as part of a multidisciplinary team.
  • Physician involvement: Placing care managers with physicians in primary care practices may help facilitate physician involvement.
  • Informal caregivers: Patients with complex health care needs, particularly those with physical or cognitive functional decline, often need the assistance of informal caregivers to actively participate in care management.
  • Coaching: Coaching involves teaching patients and their caregivers how to recognize early warning signs of worsening disease.”

The Contrast with Case Management

In contrast, case management also involves some coordination of care, but with a greater attention to controlling costs. The Case Management Society of America offers that “The underlying premise of case management is based in the fact that when an individual reaches the optimum level of wellness and functional capability, everyone benefits: the individuals being served, their support systems, the health care delivery systems and the various reimbursement sources.” They add, “Case management serves as a means for achieving client wellness and autonomy through advocacy, communication, education, identification of service resources and service facilitation. The case manager helps identify appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the client and the reimbursement source.”

In case management, patient welfare is still very important. But, it is clear that the financial side of healthcare gets more attention. For example, the Commission for Case Manager Certification writes that  “Case management services are optimized best if offered in a climate that allows direct communication among the case manager, the client, the payer, the primary care provider, and other service delivery professionals. The case manager is able to enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines.” Payers and other stakeholders get significant attention is this model.

The importance of care management and case management speak broadly to the complexity of healthcare and patients’ potential inadequacy in the face of managing their own care, especially from overlapping chronic conditions are involved. One problem is that the financial side of care and the pursuit of the best possible outcomes can sometimes be at odds. The identity of the payor may be the real arbiter of which focus—patient or cost—is the ultimate winner.

Case Management Training

With the Affordable Care Act changing reimbursement models, case managers must ensure quality care for their patients, provide effective communication to their patients and patients’ families, and coordinate physician documentation within medical records.  They also have to understand and provide guidance on correct patient status, assist with medical necessity denial management, reduce readmissions, and overcome discharge barriers.

Decisions made and actions carried out by case managers affect the quality of patient care and organizations’ reimbursement, therefore implementing a training program is imperative to the success of your organization. Our solution was developed by experts to provide essential case management training that addresses key care coordination issues and mitigate financial and compliance risk.

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