Care management sometimes reminds me of lyrics within the 50-year-old Bob Dylan song Ballad of a Thin Man-"Something is happening, but you don't know what it is" (Dylan, 1965). Most people outside of care management processes are somewhat unaware of what care managers are doing. As a care manager, I have heard the following comment in many presentations about improving care processes: "This is when we call the care coordinator or manager or navigator...." I wait to hear what they actually say the care manager does or did. There is typically not a further response about what happened once we are called, just relief that we were there.
Improving care efficiencies and managing orthopaedic clients, before and after discharge from the hospital, are nothing new to orthopaedic nursing. In 1983, when Diagnosis Related Groups capitated payments for specific admissions types, such as total hip procedures, processes were quickly streamlined for efficiency. Moving forward from almost 30 years ago, orthopaedic nurses have continued to be on the forefront of new care process initiatives now being introduced in healthcare reform. Orthopaedic conditions and interventions continue to be one of the largest users of post-acute care settings such as skilled care settings, rehabilitation facilities, and home health services (Goodman, Fisher, & Chang, 2011) and thus continue to be a constant focus of care managers.
This issue is dedicated to discussing new care and payment processes-many of which we hear about daily in healthcare-or even in general public news. A select group of writers have spent time gathering the latest evidence on topics such reviewing technology initiatives that support care management and what bundled payment structures look like in an orthopaedic case study, as well as an example of these payment structures in pediatric populations.
Now is a time for nurses to be the leaders in development and implementing care management and coordination. No better place to learn is from the American Nurses Association's (ANA's) white paper on care coordination and the Affordable Care Act: http://www.nursingworld.org/care-coordination. The ANA and others are providing a vision on how nursing is vital in healthcare reform including policy guidelines on how institutions need to identify care management-sensitive outcomes and nurses should receive payment for care management (Lamb et al., 2015).
In August 2015, the Centers of Medicaid & Medicare Services reported a $411 million savings due in part to the new Pioneer Accountable Care Organizations (ACOs). These initiatives have started slowly and are ramping up for many more healthcare organizations. Currently, many Americans have ACOs available for them but only 14%-16% are enrolled (Goodman et al., 2011); thus, the complete savings of healthcare dollars is yet to be discovered. The goals of the healthcare reform and ACOs are payment structures that incentivize healthcare systems to reduce healthcare costs by paying for outcomes of care rather than the number of services provided.
To nurses, improving our client's experiences and outcomes is often more important than saving healthcare dollars. We know that shared decision making and goal setting improve our client's care experience, we know that healthcare dollars are limited, and we know that a large factor in quality outcomes lies in coordinated, unfragmented care. Mostly, what we know if that our clients rely upon us to be advocates, to help navigate complex care systems, to assess and prioritize their needs, to provide appropriate condition-related and anticipatory teaching, and to help them see the future related to their healthcare decisions. A hope is our client's see what we are doing as nurses and care managers better than others. They know something is happening and can typically tell us what that is.
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