Case management is a collaborative process, which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health needs through communication and available resources to promote quality, cost-effective outcomes. This was one of the first standards of practice that defined case management. Case management is very important in value-based care, especially for those patients with complex, multiple chronic conditions, co-morbidities, and or SDOH behavioral health challenges. Case managers are vital to the care team and to the patients. Case managers assist patients in accessing high-quality care that is safe and efficient. They also educate and empower patients and families to understand and participate in the care plan. The ultimate goal for all patients is to achieve optimal wellness and functional capability because then everyone benefits, patient, family, caregiver, health system, payer, employer, and community. Case managers should have education in a health or human services discipline and unrestricted license or certification per state or employer. They should be able to function independently and within their scope of practice. Maintaining current knowledge, skills, and competence is extremely important for success. Case managers need to provide a holistic and client-centered approach to care for all patients they work with. They may need to provide oversight of other personnel on the team who are unable to function independently due to licensure or educational restrictions. Case management is crucial in health care due to ongoing problems such as fragmented care, poor care coordination, and lack of communication when transitioning across different levels of care, such as from an acute care hospital to a skilled nursing facility. Case management is critical for preventing bad health outcomes. It is about closing gaps in care. For example, ensuring that a patient has a colonoscopy so that he doesn't develop colon cancer. Communication from one level of care to another or between health care providers is often lacking and can cause harm to patients. Health care is complex to navigate, and with an aging population accessing multiple services from various providers, it is extremely beneficial to have a case manager to help and vocally advocate for a patient. Case managers identify high-risk patients or populations based on actionable data and use evidence-based guidelines to promote collaborative care coordination. They utilize standard practice tools to assist patients. Case managers help patients to safely navigate when transitioning care by conducting follow-ups after hospital discharges, ER visits, urgent care visits, and in-patient rehab facility, IRF, discharges. Case managers have been shown to improve the patient or family experience and ensure safe quality outcomes that are cost-effective. They identify reasons for barriers to care and how to overcome these challenges, which helps develop a collaborative, high-functioning case manager. Not every patient needs care management. Let's look back at the population health pyramid you explored in Course 2 on population health. Here, we are talking about those patients in the top tier of the pyramid. Attempting to case manage individuals who do not want or need the additional focus will be frustrating for both patients and care team and will expend resources the practice could use elsewhere. That being said, for each patient in need of case management, case managers should develop a care management plan of care that is patient-specific and patient-centered with care goals, needs, and preferences. The patient and caregivers should be involved, understanding, and agreeing to the plan of care. The plan may include chronic care management, disease exacerbation management, and or self-management. Case management can be performed in person, by telephone, or via distance monitoring. Follow-up should be on a regular, frequent basis. Case managers need to connect with patients and caregivers to build trust. Also, case managers should anticipate patient needs. Patients and caregivers need to have direct access to the case manager. There should be no delay in getting a response to their questions or needs. The case manager should be involved in facilitating access to the PCP, specialist, ancillary, home health services, hospice care, etc. Case managers must focus on targeted populations and be accountable for cost-effective quality outcomes. Patients who would be potential high-risk cases are those recently discharged from an acute care hospital, emergency room, or post-acute facility. Also, patients with multiple co-morbidities that are not well-controlled or at goal should be referred to a case manager. These referrals could come from the PCP, from a care team member, or through self-referral.
