1. Watson, Annette C. RN-BC, CCM, MBA

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For many years, professional case managers have stressed the value of case management services in achieving desirable outcomes across the health and human services spectrum. Board-certified case managers, in particular, can attest to the benefits of such services as care coordination and care management to both the individual (i.e., the case management "client") and the health care system as a whole.


Now, in this era of health care reform, the system is increasingly looking to case managers to measure and evaluate quality and outcomes. As a key member of the team, the professional case manager is being tasked with the quality and outcomes of care delivery systems and their impact on the individual's experience of care. In pay-for-performance programs, these measures have a direct impact on reimbursement for providers from private payers as well as the Centers for Medicare and Medicaid Services. Given the financial impact on hospitals, subacute facilities, primary practices, and other care settings, the professional case manager shoulders significant responsibilities for tracking quality and outcomes, as well as targeting improvements-not just for the case manager's own performance, but for the performance of the team and even of the organization.


Measuring quality and outcomes has become such an integral part of case management practice, it is now considered an "essential activity," as defined by the most recent role and functions study conducted by the Commission for Case Manager Certification. (See "Informing the Content and Composition of the CCM Certification Examination: A National Study from the Commission for Case Manager Certification-Part II," page 3, this issue.) "Evaluating and Measuring Quality and Outcomes" is one of the two new domains identified in the role and function study, the other being "Adhering to Ethical, Legal, and Practice Standards" (Tahan, Watson, & Sminkey 2016). Previously, following the 2009 role and function study, ethics and quality management were embedded in other domains in the form of subdomains or major knowledge points.


For individual case managers, greater prominence being placed on evaluating and measuring quality and outcomes means these responsibilities are increasingly part of their regular jobs and day-to-day responsibilities. These responsibilities include such things as using evidence-based practice guidelines to develop the case management plan; monitoring the individual's progress in achieving the goals, objectives, and outcomes of the case management plan; evaluating health care services received; collecting and analyzing outcomes data; evaluating availability, timeliness, and quality of treatment, interventions, and services; and evaluating the individual's outcomes versus expected outcomes.


What quality and outcomes responsibilities look like for each individual case manager will vary somewhat based on practice setting. For example, a hospital-based case manager may be tasked with improving care transitions and reducing readmissions in order to avoid penalties and reduced payments from Medicare and other payers because of excessive readmissions within 30 days of discharge. Other case managers who specialize in workers' compensation or vocational rehabilitation have their own quality and outcomes to be measured, such as the individual's ability to perform activities of daily living or to transition back to the workplace while healing and recuperation continue.


Quality and outcomes are being emphasized more than ever in primary care practices, accountable care organizations (ACOs), and patient-centered medical homes (PCMHs). Here, professional case managers are being asked to monitor and evaluate emergency department (ED) visits or inpatient services for "ambulatory care sensitive conditions" (ACSCs) within their patient populations. The Agency for Healthcare Research and Quality (AHRQ) defines ACSCs as conditions for which good outpatient care can potentially prevent the need for hospitalization, or for which early intervention can prevent complications or the onset of a more severe disease. These indicators are used to determine the quality of the health care system outside the hospital setting (AHRQ, 2001).


For the ACO, PCMH, and the primary practice, evaluation of outcomes for patients with ACSCs might look at how ED visits and hospitalizations could have been reduced or eliminated. For example, were there missed opportunities for better follow-up with the patient? Were physician orders followed? Would better medication management or more frequent interaction between the individual and the primary care physician and/or specialist have made a difference? A board-certified case manager is a highly qualified clinical professional to handle these responsibilities. If there is a breakdown in the system, a board-certified case manager's expertise is necessary to identify the cause and address how to prevent it from reoccurring. For example, did the patient go the ER unnecessarily because he/she did not have access to a physician or did not know what to expect at a particular stage of a health event, such as after surgery? This kind of critical thinking and clinical analysis can prompt discussions with patients and other members of the team that result in changes, which, in turn, can lead to improved outcomes consistent with the triple aim: better care, better health, and better costs.


The professional case manager may also be tasked with determining individuals' risk levels and the appropriate intensity of intervention. Is the individual a high-risk patient who should receive case management services on a regular basis? Does the individual have intermediate risk and therefore should receive other interventions from a team member, such as a health educator or nutritional counselor? Or, is the person low risk, requiring minimal monitoring and with escalation to the professional case manager only if health status changes, or has this person missed wellness care interventions such as mammograms, flu shots, and so forth.


Professional case managers are also being called on to play a role in population health management; for example, by using information in electronic medical records (EMRs), reviewing regular reports, and accessing claims-based data via portals provided by payers, they can determine whether individuals who should be having regular screenings or an annual wellness visits have done so. Patients with more complex needs (e.g., having two or more chronic conditions) may receive services for "transitions of care" and "chronic case management" to help improve outcomes. In fact, some of these "non-visit" services can be billed to Medicare and other payors provided that eligibility criteria are met. This means that some case managers may begin to have their performance measured according to revenue generated by their involvement with a patient-not just by savings generated from case management interventions.


As these few examples show, the specifics of evaluating and measuring quality and outcomes will differ, depending upon practice setting and professional discipline. The spirit of this essential activity, however, remains the same: using evidence-based practice to achieve desired goals and evaluate outcomes and quality. In addition, the essential activities and knowledge domains of current case management practice, as determined by the role and function study, establish common ground for professional case managers to interact. When two case managers, both of whom are board-certified, are involved in a care transition (e.g., from acute to subacute, or subacute to home or community resources), each professional knows the importance of providing comprehensive, person-centered services and support in pursuit of the individual's goal. Moreover, as quality and outcomes improve overall, there is better utilization and stewardship of scarce and costly care and treatment resources across the health and human services system.




Agency for Healthcare Research and Quality. (October 2001). AHRQ Quality indicators: guide to prevention quality indicators. Retrieved July 30, 2015, from[Context Link]


Tahan H. A., Watson A. C., Sminkey P. V. (2016). Informing the content and composition of the CCM(R) Certification Examination: A national study from the Commission for Case Manager Certification-Part II. Vol. 21, No. 1, 3-21. [Context Link]