1. Owen, Mindy RN, CCRN, CCM

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In 2014, as in every year, the Editorial Board of the Professional Case Management gathered as a time to reflect on the continual evolution of the practice of case management and, what we believe, may be on the horizon. Under the leadership and guidance of Suzanne K. Powell, the Editor-in-Chief, this Editorial Board, rich in practice experience and diversity, takes the opportunity to listen to and learn from each other, noting what we have experienced in the last year. Each year, it is a time to take the pulse of the practice of case management and health care in general.


Often, the conversations continue via e-mail during the subsequent month(s). I would like to take the opportunity to share some of the questions that were asked of the Editorial Board, and the reflections that ensued.


Those of us who have practiced in an acute care setting for 15 years, 20 years-or longer-have seen significant changes in the populations we serve today. Simply put, populations that we engage with in the acute care setting come in with a more complex presentation. They are either unable to access outpatient care timely or have gone to a provider who may not be aware of the patient's total health care picture. They may have multiple providers whom the patient assumes communicate (which is often not true), therefore leaving it up to the providers to determine the best plan of care. By the time a patient comes into the acute care setting, they may be sicker than they would have been if they had accessed care earlier; yet, under the rules and regulations of reimbursement or contractual obligations, the patient may be transitioned out of the acute care facility earlier than the patient or family feels comfortable or is ready, leaving everyone with a heightened level of anxiety.


Is the patient in the facility an observation patient or do they meet inpatient criteria? And who explains what this means (fiscally and health care wise) to the patient and the family; who helps them work through the maze of care and questions on reimbursement? Today, more than ever before, we (health care providers) talk in short hand and yet assume that everyone understands and take very little time to confirm that the message we are sending is the message that is received. Is the patient engaged? Is the family engaged? Is the physician engaged? Or, are we all in silos speaking our own language and not listening to one other?


The overarching question posed to the Editorial Board was: Is the perception that the acute care case manager has more complexity in their role today than 5 or 10 years ago, an accurate perception? If so, what could be some of the reasons?


Often, families appear to be more reluctant to take responsibility for elder care, necessitating a rise in guardianship and public proceedings to secure safe and appropriate intervention. We are all leaning on state funding and limited financial resources to support "ongoing" care outside of the home.


Question: Is this a fair assessment nationwide and, if so, are there any answers?


There appears to be an increase in patients who are "truly self-insured," needing post-acute care with resources that are extremely limited or not available. Are we in case management asked more often than in the past to "find a placement" when there are no financial resources, or the care needs of the patient are so complex or difficult that community resources are not equipped to handle these needs?


Question: Is this a fair assessment nationwide and, if so, are there any answers?


There appears to be a rise in patients needing a combination of medical and behavioral health interventions. Again, resources appear extremely limited, therefore mandating that patients remain in acute settings that may not be supporting their needs holistically. This also raises issues for case managers around how and what they share regarding a patient's overall physical and mental presentation. Ethical questions become apparent.


Question: Is this a fair assessment nationwide and, if so, are there any answers?


Patients and families come to the health care arena with a sense of entitlement. They have a limited understanding, if any understanding at all, that resources and options may not be available. They come in at a time of high stress due to an injury, serious medical diagnosis, or complex care plan, expecting that anything that is recommended will be done, regardless of resource allocations.


Question: Is this a fair assessment nationwide and, if so, are there any answers?


What is the definition of Case Management today? Are some "case managers" tied to utilization management? Are some considered the discharge planners? Are we perceived as in silos and therefore focused on tasks and "stuff" rather than the depth and breadth of what we ultimately should be contributing to the overall care plan and transition of our patients? We contribute to the fiscal sustainability of our organizations by realistically pulling the patient through the system, as well as quality of care? At times, I am not sure that our position and value are apparent.


Question: Is this a fair assessment nationwide and, if so, are there any answers?


As more and more medical homes become established, and accountable care organizations are part of the health care landscape, are their tools and interfaces in place to seamlessly transition patients between providers, systems, and interventions (both acute and outpatient) in a manner that is understandable to patients, families, and the team? Many times, I hear that we find confusion and a lack of understanding as to:


* "Who do I take my questions to?"


* "How do I get help for my symptom management when I have 4, 5, 6 (or more) providers?"


* "How do I confirm an appointment or next intervention?"



If the system is confusing-or at least not clear to those of us who are "inside"-how can we expect the patients and families we serve to understand and take the steps necessary to manage their care?


Question: Is this a fair assessment nationwide and, if so, are there any answers?


"Physician Engagement" has been acknowledged as a challenging component to sustainable future models of care. Physicians are "grieving" how medicine used to be; we see this and can, at times, relate. However, several insightful physician leaders are suggesting that our "system" as it is today is unsustainable, that physician goals, objectives, and compensation must all be realigned and focused on a "true fit" within health care systems to meet fiscal, quality, and the patient experience goals and metrics. At this time, we often see competing incentives.


Question: Is this a fair assessment nationwide and, if so, are there any answers?


As one of the Professional Case Management Editorial Board members reminded us, the Affordable Care Act was not to be the "be all, end all," but to open a transparent dialogue that would begin to shift the discussion and culture to addressing health care issues, rather than continuing to pass the buck.


With the research that we are seeing today, it is becoming clearer that, without a cultural shift from managing sickness to focusing on health, we will not be able to sustain our health care system for future generations.


The crystal ball shows that acute care facilities will be focusing on the sickest of the sick and referring many interventions that were considered hospital-based only to be provided in outpatient or home settings. Who will help a patient and family manage expectations, encourage them along the way, and provide a structure that focuses on stress reduction? We have all seen patients with new and complex health situations go home, panic, and readmit.


Telemedicine is increasing in scope when assessing and implementing a plan of care. Emergency departments-with the assistance of case management-are becoming triage and transition-of-care focal points, reducing unwarranted admissions and ensuring care at the right time and in the right place.


I asked the question earlier in his column, "What is the definition of case management today?" I believe that due to our varied experiences and expertise, as well as our various practice settings, we all may answer a little differently.


I believe that what is essential in the definition of case management is an approach that is patient-centered, focusing on transitions of care, at the right time, in the right place, and for the right reason ... and at a level of communication and education that is driven by the patient and family.


My crystal ball remains fuzzy and I do not have the answers to many of the questions posed. But what I do know is that case management continues to be vital to quality care, sustainable patient engagement, fiscal responsibility, and effective and efficient communication. It is the BEST HARDEST practice I know .... Let us continue to explore the questions, and please share any answers along the way.