Updated: Oct 30, 2020
Today’s Case Manager role is multidimensional and pivotal for many reasons – the healthcare landscape continues to evolve, discharge planning and transition from episode of care to community to reduce readmissions and improve patient experience is a must, financials of care need to be addressed as there is not an open checkbook – insurers and other governmental agencies are not going to pay for care that is not efficient, value-laden of quality, and provide a positive patient experience and promote patient safety. In light of the demands of healthcare today, knowledge of existing research findings that foster case management best practices is important for all involved - on the front-line or leadership to support evidence-based Case Management practice.
In March 2010, President Obama signed The Patient Accountability and Affordable Care Act (ACA) to broaden access to high quality cost-efficient care for all Americans. Most notably, the legislation established a National Strategy for Quality Improvement in Healthcare (the National Strategy) which emphasized patient centered, accessible and safe care for the overall improvement of the nation’s health. The necessity of identifying interventions that promote health while recognizing varied determinants of (behavioral, social and environmental) of health is necessary for health care quality and to facilitate a reduction in cost for quality services provided for all Americans(1).
Although there have been attempts at legislative appeal of the insurance mandates of The Affordable Care Act requirements for the delivery of cost-effective healthcare remains. Measurable quality services focused on optimal patient outcomes and patient experience is here to stay. Recognizing the importance and promoting integration of the Case Manager role is essential in these efforts.
Improved service delivery and coordination by all health care professionals working together in a multi-disciplinary fashion to ensure coordinated care and a positive patient experience is most important. For this reason, many hospitals - safety net, urban and rural – as well as medical systems and community health, have restructured care coordination programs, to further ensure a positive patient experience, decrease readmissions, and promote better patient outcomes. --maintained in each level of transition – from hospital, to ambulatory care, to community services, to primary care.
Examples of restructuring has included assignment of case managers from unit to service-based coordination of care(2), integration of care coordination functions in primary health care organizations (PHCO’s)(3) and provider-sponsored organizations (PSO)(4), patient centered medical home (PCMH), accountability care organizations (ACO), implementation of at-risk financial models to more adequately monitor readmission rates, length of stay and patient experience(4),(5). Varied quality improvement actions can be incorporated to advance scores on quality measures as by example of “Case Study Series on Hospital Patient Experience Measures: Improvement Strategies of Top-Performing Hospitals”, published the Commonwealth Fund.
Reported examples of positive patient results influenced by changes in care delivery include improved patient experience resulting from improved coordination and accessibility of care(3), (6) ,(5), quality and coordination of care for persons who are multilingual(6) and low-income, those with need for continuing treatment and follow-up(7), and where increased patient adherence to needed medical care(7) is the result. For instance, interventions implemented among populations to improve patient outcomes include studies with interventions that include patient navigation and home telehealth. A review of a number of studies focused on the coordination of care among cancer patients in particular demonstrated an 81% improvement in quality and patient experience when these interventions and/or improved care coordination occur(8). Overall health care utilization was two times more appropriate when these interventions took place. This is the type of continuing research needed to understand how care coordination has a positive effect (or not), and thus lead to evidence-based practice for the care team.
Recent studies explore patient differences that may influence outcomes, e.g. variations in in diagnoses and / or case-mix, and patient hospital experience. In several studies, case mix and service diagnosis were found to influence patient hospital experience. Increasing complex patients, experience with emergency admissions had fewer high scores when compared to those patients with a cancer diagnosis. Varying surgical specialties that resulted in the need for increased coordination of care, attention to pain control, nursing and medical care differed significantly on survey among hospitalized patients covered under Medicare(9) as a for instance.
Interventions implemented to improve care coordination include post-discharge phone calls in the elderly for follow-up for medication fills(6),(10). Results are mixed as to whether this intervention influences self-care, among all age groups. For instance, in one study little difference resulted in quality scores in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), or patient survey among hospitalized Medicare patients that are publicly reported and can directly influence Medicare reimbursement(9) . Another study report indicates that general medical patients over the age of 18 discharged home from hospital, post discharge calls did not have a reported effect when exploring adherence to treatment plans and emergency readmissions. As there are differences in level of care and types of patients, this might be an example that requires a pilot study to evaluate impact and benefit in your organization.
Other surveys that can measure aspects of patient experience and care coordination and aspects of quality in care transition hospital to community include the Care Transitions Measure (CTM-3), Patient Experience Questionnaire (PEQ) and the Medical Home Care Coordination Survey (MHCCS). Looking at these surveys and others may be helpful as measurement of quality, patient experience, access to care, outcomes of care are ever increasing important considerations.
What is the take-a-way from all?
· The role of the Case Manager is an ever-increasing important one in the process of care delivery; Case Managers can be an effective contributor to positive patient and family experience. In particular, questions that can be asked include is patient experience more favorable when care coordination occurs? Does the patient and family understand the role of a case manager in care coordination and facilitating successful patient outcomes?
· Case Managers have opportunity to improve quality through ensuring access and communication, in addition to overall coordination and patient inclusion in decision-making can result(11), (12).
· The emphasis continues on quality – there are quality measures that can be instituted within a Case Management department that can measure your success and provide information as to opportunities for improvement as compelled by today’s healthcare expectations.
· Take the time to review best practices of other organizations through a review of research available – share your articles at rounds or a department meeting.
· Encourage others to move forward in the study of a proposed improvement to enhance excellence or information shared might tell you that others have tried similar intervention and there is not enough supporting evidence to waste your time and energy in an already challenging day!
Professional Services Network, Inc. (PSN) works with clients nationwide in the search and recruitment of experienced nurses in utilization review, quality and case management for temporary assignment and direct hire opportunities.
PSN has added a focus on the importance of research in healthcare through its additional focus – Nursing Research Matters. If you or someone in your organization would like to discuss ways we might help in staff or organizational development into evidenced – based Case Management, call us today for a ½ consultation.
1. 2011 Report to Congress: National Strategy for Quality Improvement in Health Care. Content last reviewed October 2018. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/workingforquality/reports/2011-annual-report.html
2. Amin, A. N., et al. (2014). "Reduce readmissions with service-based care management." Prof Case Manag 19(6): 255-262.
3. Borges Da Silva, R., et al. (2018). "Nursing Practice in Primary Care and Patients' Experience of Care." J Prim Care Community Health 9: 2150131917747186.
4. Schiller, K. C., et al. (2010). "Patient assessments of care and utilization in Medicaid managed care: PCCMs vs. PSOs." J Health Care Finance 36(3): 13-23.
5. Granata, R. L. and K. Hamilton (2015). "Exploring the effect of at-risk case management compensation on hospital pay-for-performance outcomes: tools for change." Prof Case Manag 20(1): 14-27; quiz 28-19.
6. Chan, B., et al. (2015). "The Effect of a Care Transition Intervention on the Patient Experience of Older Multi-Lingual Adults in the Safety Net: Results of a Randomized Controlled Trial." J Gen Intern Med 30(12): 1788-1794.
7. Broaddus, M. R., et al. (2015). ""She makes me feel that I'm not alone": linkage to Care Specialists provide social support to people living with HIV." AIDS Care 27(9): 1104-1107.
8. Gorin, S. S., et al. (2017). "Cancer Care Coordination: a Systematic Review and Meta-Analysis of Over 30 Years of Empirical Studies." Ann Behav Med 51(4): 532-546.
9. Thiels, C. A., et al. (2016). "Effect of Hospital Case Mix on the Hospital Consumer Assessment of Healthcare Providers and Systems Star Scores: Are All Stars the Same?" Ann Surg 264(4): 666-673.
10. Soong, C., et al. (2014). "Do post discharge phone calls improve care transitions? A cluster-randomized trial." PLoS One 9(11): e112230.
11. Hudon, C., et al. (2015). "Case Management in Primary Care for Frequent Users of Health Care Services With Chronic Diseases: A Qualitative Study of Patient and Family Experience." Ann Fam Med 13(6): 523-528.
12. Joo, J. Y. and M. F. Liu (2018). "Experiences of case management with chronic illnesses: a qualitative systematic review." Int Nurs Rev 65(1): 102-113.
About Nursing Research Matters
The aim of Nursing Research Matters is to offer helpful information and story examples regarding how nursing ideas can be 'discovered' and studied and how findings can be effectively communicated. Focus on nursing innovation includes a focus on the communication of nursing best practices derived from nursing research that can be incorporated for successful change. For more information visit www.nursingresearchmatters.net