1. Powell, Suzanne K. RN, MBA, CCM, CPHQ


2014 Healthcare predictions affecting case management are an inexact science. However, some issues will continue to be front and center as we navigate a health care environment that is changing at the speed of, well, health care.


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The last time this Editorial had "predictions" was back in 2008, for 2009. At that time, I utilized my Editorial Review Board-many of the best in case management-as my "think tank." Some of the predictions withstood the test of time: aging of the case management workforce (although that did not take a "crystal ball"); the practicality of medical homes; that safe transitions of care would continue to have a major impact for case managers; that RACs, HACs, MACs, and other regulations would keep case managers running, and the confusion created by the plethora of new titles and job descriptions.


I took another "pulse" on the future of case management with a smaller group. Some of the issues remain consistently troublesome. New issues and regulations are emerging and only a "time traveler" could predict how they may play out. Before we list some insights by my mini-think tank, Ellen Fink-Samnick, Stefani Daniels, and Hussein Tahan, I have a slam-dunk prediction for the PCM Journal: that PCM Journal's new department starting this issue will be a major contribution to case management.


As you know, we wished Fran Snowden the best in her retirement. With that retirement, we put "Return to Work" in semiretirement. I say "semi" because our new department, Case Management (CM) Matters, will continue to address return to work issues. It will also broaden to include all types of case management, because it ALL matters. The Case Management (CM) Matters department reports on emerging trends, tools, techniques, unique experiences, and models that relate to all case management practice.


Case Management (CM) Matters Section Editor is Lynn S. Muller. Many of the readers know Lynn, a nurse attorney and managing partner of Muller & Muller. She is an Adjunct Professor in the Doctor of Nursing Practice (DNP) program at Saint Peter's University of New Jersey. Lynn is a certified case manager (CCM) with extensive nursing and case management experience. Her practice includes defense of health care professionals before the state licensing boards, consultant on such issues as regulatory compliance and accreditation, civil litigation, wills, trusts, and estates and family law. Lynn has been and continues to oversee the Legal and Regulatory Issues department in the journal.


And now, some of the 2014 predictions:


1. Increased psychosocial stressors: In every arena of case management, case managers will continue to struggle with societal psychosocial stressors and their manifestation. Gross increases in mental illness will continue to fuel integrated behavioral health approaches; enhanced access to appropriate resources and knowledge of interviewing strategies such as motivational interviewing and patient engagement will work toward greater adherence with treatment. As case managers become more involved in primary and secondary prevention, health literacy assessments and activation measurement are necessary to understand level of engagement and strategy-specific interventions.


2. Changes in the "center" of Healthcare: Hospital inpatient rates will continue to decrease. Coordinating community-based care among disparate providers through an accountable care organization or medical home, without sacrificing quality or access, will fall to a case manager. Hospitals are increasing their community footprint as a unified health care system with the acquisition of, or affiliation with, post-acute care providers. Case managers will be the new navigators for selected patient populations to pilot patients and families through these complex organizations. Health care will move more and more into outpatient settings. Acute care will not be the center of care; rather, community-based clinics and medical homes will become center. In addition, an episode of acute care will start up to 7 days prior to actual admission and extend to a minimum of 30 days postdischarge (maybe longer). However, in the acute setting, the impetus for the return to the original progression of care models of hospital case management will percolate from within the hospital, as executives seek to streamline care coordination activities and promote physician engagement.


3. Value-base purchasing models will override other models. Providers will increasingly assume more financial risk, with the aim to demonstrate value, ultimately resulting in increased revenue. Many value-based agreements provide incentives for the provision of high-quality care that meets certain benchmarks. Others are more complex and may include capitated payments for a patient over a set period of time or bundled payments for certain medical and surgical services. Hospitals are entering into risk arrangements with large commercial payers, based on their ability to efficiently coordinate care between the hospital and post-acute care providers for continuity of care. Case managers will lead these efforts. And, measuring clinical process of care will continue to escalate, affecting payment to physicians and hospitals. Case managers are among the few roles in the health care industry who are able to combine the business and clinical interests of multiple stakeholders through progression/coordination-of-care strategies.


4. Telehealth challenges: Ethics and legal issues will continue as paramount in the Tele-times, with increased interest for case managers, and other licensed professionals to navigate licensure and reimbursement issues for telehealth and telemedicine. While many continue to negotiate practicing across state lines and cyberspace, laws and regulations continue out of sync with reality, although the fight to forge change advances. Increased legislation across the states and at the federal level to reduce both licensure barriers and increase portability is expected.On the legal side, health care's new Quality Trifecta will race ahead at warp speed with increased incidences hitting the media: Patient safety, privacy and security, Medicare fraud will be hot buttons for organizations to reconcile whether the hazards are related to IT mishaps, electronic health record system failures and/or order entry mistakes, continued data compromise and fraud related to documentation cloning, and billing, to name a few. For example, in 2013, a $1 Billion system and its backup crashed. And, in September 2013, UnitedHealth Group Inc. recalled software used in hospital emergency departments in more than 20 states because of an error that caused doctor's notes about patient prescriptions to drop out of their files (Robertson, 2013). These incidents demonstrate how system errors and crashes can create dangers for patients at a time when digital health records are being implemented as a cornerstone of health care.


5. Definitions for Case/Care Management and the Need for Title Protection: The ramifications of "anyone" calling themselves a "case manager" (or even the nebulous and confusing "coach" definitions) can dilute the professionalism and confuse public perception; further, with the numbers of case managers increasing in all environments of care, the consistency of roles and functions has never been more critical.


6. HACs, RACs, MACs, and other Regulatory MEGA Trends Affecting Case Management Work: Acronyms such as HAC, RAC, HCAHPS, MAC, POA, HAI, P4P, and VBP (to name a mere few) will impact our organizations and our case management lives-the pace of the changes will continue to intensify. We must become more knowledgeable about our organizations' financial reimbursement and understand the impact of political trends on funding for programs and resources ... because as this evolves, case managers will be expected to help reduce clinical costs associated with practice variations through the use of evidence-based medical protocols, specific documentation, and accountability.



As PCM Journal has said and will continue to support: we must take care of ourselves to have anything left for our patients/clients. Assessing and developing resiliency for oneself and in one's workplace is critical for long-term survival in a stressful case management environment. Use of humor as a healing force in health care is well-documented. The seriousness, sensitivity, and sincerity of case managers are a staple of our profession. Case managers must actualize-in everyday practice-the value proposition of a health-promoting belly laugh, a tension-reducing chortle, or even a smile-producing pun (PCM Editorial Review Board, 2008). In 2014, wishing all case managers resilience and equanimity.




PCM Editorial Review Board. (2008). The PCM Journal "Think Tank" on case management predictions for 2009. Professional Case Management Journal, 13(6), 299-301. [Context Link]


Robertson J. (9/9/13). UnitedHealth recalls digital health record software. Retrieved September 10, 2013, from[Context Link]


regulatory trends; value-base purchasing; telehealth