1. Alejandro, Jose PhD, RN-BC, MBA, CCM, FACHE, FAAN
  2. President, CMSA National Board 2018-2020

Article Content

Health care organizations continue to struggle with the changing reimbursement methodologies that continue to transform the way health care is delivered. Historically, care management (case management, social work, and care transitions) programs have been focused on how to safely transition patients/residents/clients to a different level of care through an established discharge planning process. Today, case managers must also have an increased awareness with regard to the quality of care provided by the accepting organization and whether they are part of an approved network.


Risk-sharing arrangements are becoming more prevalent, and care management is a focal point. Organizations are beginning to embed revenue cycle and managed care contracting components within their care management domain. Predecessor case management programs truly focused on the revenue cycle to qualify the patient and discharge planning once the patient no longer qualifies for inpatient from the financial perspective. Traditional silos within care management, contracting and finance departments are now required to collaborate in order to effectively manage the transitions of care. These key stakeholders need to build a clinical-financial bridge that works collaboratively to proactively manage at-risk populations, also known as vulnerable populations.


Care management leaders are being thrust into new roles and responsibilities that will require us to change our mental and practice models. For example, shouldn't we now have a "transition planning process" instead of a "discharge planning process"? Truly, it is no longer a quick handoff of care from one transition point to another. We need to consider how we can transition our established care management models into a model that integrates traditional core functions within a population care model. Health care organizations will be required to rebalance and redeploy staff to meet these additional responsibilities that will require collaboration with internal stakeholders and external partners. This may mean addressing legacy programs that may need to end so that employees can be resourced to new programming. Chief financial officers will become hesitant to continuously add new positions without having a focused review of current programming.


In addition, we need to pay special attention to the social determinants of health and develop strategies that quickly and proactively identify care transition barriers much earlier than when arriving in the acute care arena. There continues to be a need to integrate clinical social work, mental health, and community support services into the transition planning process that addresses unique communities, patients, families, and caregiver needs. Critical thinking, creativity, and relationship building will continue to be prerequisite skills of today's care management professionals.


Care management staffers assist interdisciplinary teams and caregivers in developing strategies and interventions to effectively and efficiently provide exceptional care. Understanding and knowing clinical milestones can assist the entire care team in clinical time frames and individual care goals and address potential transition needs and barriers instead of focusing on reactive discharge planning activities. Most importantly, it keeps everyone on the same page and promotes consistent communication to the individual being cared for. Again, proactive and anticipative care management is far more effective than reactionary care management. Thus, care management delivery models become more robust when care management professionals practice at the top of their scope of practice. From time to time, we should assess what additional tasks have been delegated to care management disciplines and evaluate whether they are consistent with care management professional practice.


Many organizations continue to struggle with emergency department boarders due to high inpatient census and/or services that are not available. An example, inpatient psychiatric beds are limited throughout the country but the incidence of mental health continues to rise without including the discussion on substance abuse. The strain of inpatient throughput adds pressure to care management teams to focus on discharge planning that can lead to focusing on those who are much easier to transition to another level of care. Long-term patients can increase without intent if the focus becomes singular on those who can be transitioned. Focusing on the reaching clinical milestones while leveraging internal and external relationships can result in patients and families being more open to alternate levels of care at the right time.


Care management professionals are important stakeholders within the interdisciplinary team and oftentimes help connect the dots between disciplines. Most importantly, care management's work facilitates reaching clinical milestones while developing a pathway to care transitions. As members of the interdisciplinary team, care management professionals provide valuable insight into the development of a realistic transition plan. Interdisciplinary transition planning is an opportunity to explore options and consider different perspectives. Involving the individuals who we care for and their caregivers in transition planning respects their rights to make informed decisions and builds trust of our health care delivery system. It also provides us with a valuable opportunity to understand their wishes and perspectives in regard to their care. Health care organizations that implement interdisciplinary team rounding and/or case study reviews oftentimes are more successful in promoting the appropriate interventions in addressing care progression and transitions of care.


Strategically, care management programs need to develop strategies to strengthen horizontal relationships to improve transitions of care. Health care transformation necessitates the development of a care network, whether formal or informal, that provides needed care across the continuum. Effective communication and alignment of services will strengthen the care management teams the ability to appropriately transition care. Networking within our profession is a great way to build relationships and awareness of how different organizations and levels of care can be coalesced to form a cohesive transition pathway.


Development of strategic partnerships helps us understand the capabilities of our community partners. Many communities have a number of social service organizations and governmental agencies that are very willing to assist when there is a special need within their community. The power of collaboration should not be underestimated.


"The future of our practice lies in the quality of our performance, as well as our outcomes" (Case Management Society of America, 2016). The only way to understand how we are doing as a case management function is to track clinical and business outcomes over time. To effectively respond to our changing health care delivery system, we need to use date to drive decision making. In the age of big data, we need to understand what valuable data are and what frankly distraction is. It is critically important that care management professionals develop skills and competencies related to quality and process improvement.


Sometimes, care management teams may shy away from participating in improvement activities as they may not feel confident or comfortable in regard to understanding or applying improvement tools and methods. The only way to overcome this fear is to participate and understand the value that you bring to an improvement team. Your ideas, suggestions, and knowledge bring a unique and valuable perspective to improvement efforts that lead to patient satisfaction and staff engagement.


The one thing that is a constant is change. As professionals, we need to embrace continuous learning and actively seek opportunities to advocate for our profession and the individuals to whom we serve. "The case (care) manager is uniquely positioned as an expert in care coordination and advocacy for health policy change to improve access to quality, safe, and cost effective services" (Case Management Society of America, 2016). Care management is no longer a "behind-the-scenes" function. Care management professionals provide value, and it is important that we effectively communicate what we bring to the table. We are an integral member of the interdisciplinary team and bring knowledge and key skills to facilitate transitions of care. Care management programs need to focus on care progression and transitions of care, whereas utilization management teams focus on the revenue capture. Collaboration is the key for the organization to be successful. A health care organization that focuses on quality of care with the appropriate documentation leads to the financials warranted for the organization to thrive.


Jose Alejandro, PhD, RN-BC, MBA, CCM, FACHE, FAAN


President, CMSA National Board 2018-2020