Embedded Case Managers: Program Strategies to Advance the Triple Aim and Promote Value-Based Care (Part 2)

Pat Stricker, RN, MEd
Senior Vice President
TCS Healthcare Technologies

The use of embedded case managers (ECMs) at the point of care continues to grow each year as the healthcare industry recognizes that they are critical to the development of programs designed to advance the Triple Aimand promote value-based care delivery. Last month’s article, Embedded or Co-located Case Managers: A Critical Component of Value-Based Care, explained the evolution of embedded case management (ECM) programs, defined the roles and responsibilities of embedded case managers (ECMs), noted the growth of case management positions, discussed the rapid growth of ECM programs, and reviewed program results. This month’s article will focus on the overall goals, objectives, strategies, operational challenges, success factors, and lessons learned.

Background

In 2001, the Institute of Medicine (IOM) released a detailed report, Crossing the Quality Chasm: A New Health System for the 21st Century, examining the chasm that divides what healthcare should be versus what healthcare actually is. The report pointed out that not only was the healthcare system lagging behind in providing ideal care, but that it was not even fundamentally able to reach the ideal. This was a wake-up call to the industry. It meant that in order to achieve improvements in healthcare, monumental changes needed to be made to the entire system.

The report described six Aims for Improvement that needed to be made to the whole healthcare system. These aims specified that healthcare must be:

• Safe: This must be a main focus and goal of the entire healthcare system. It is more than "do no harm." It means no one should ever be harmed by healthcare.

• Effective: Medical science should be used to assure the best available treatment techniques are used and to prevent the overuse/underuse of these techniques.

• Patient-Centered: The patient’s culture, social background, and needs must be respected. Patients must be encouraged to actively participate in making healthcare decisions.

• Timely: Care should be prompt. Delays that do not provide information or time to heal should not be tolerated.

• Efficient: Continuous effort should be focused on reducing all types of waste (equipment, supplies, space, utilization, and time) in order to ultimately reduce costs.

• Equitable: High-quality care should be available to everyone regardless of race, ethnicity, gender, or income.

These fundamental changes to the entire healthcare system seemed overwhelming, as it meant changes needed to be made to every aspect of healthcare: the patient experience, policies, payments, regulations, accreditation, professional training, procedures, etc., as well as all healthcare environments, e.g., hospitals, clinics, sub-acute and outpatient facilities, health plans, pharmacies, etc. It also required changes to local and national governmental agencies dealing with healthcare. Donald M. Berwick, MD, MPP, former President and CEO of the Institute for Healthcare Improvement (IHI) and one of theChasm report’s architects said, "No matter where you are, you can look at this list of aims and say that at the level of the system you house, the level you’re responsible for, you can organize improvements around those directions." He was calling for everyone involved with healthcare to make whatever changes they could at their level to help promote these six improvement aims and to include them, whenever appropriate, in all programs and initiatives.

The IHI continued to work on defining these aims, which led to the development in 2007 of the Triple Aim: a simultaneous pursuit to:

• Improve the entire patient care experience, as defined by the six improvement aims noted above. It should not be focused on only improving patient satisfaction.

• Improve the health of populations, which is a widespread approach that requires the engagement of partners across the community, not just within the healthcare systems.

• Reduce per capita (per person) health care costs and allow organizations to use the resources in other ways. It should not focus entirely on cost reduction, but rather the value received from the money invested.

The IHI noted that the Triple Aim is actually a single aim (improving the entire U.S. healthcare system) with three separate dimensions. While some organizations modify the dimensions, the IHI stresses that this should not be done. Modifications can weaken the overall Triple Aim framework and alter the significance and degree of changes needed.

It took awhile for this framework to be understood, but new, innovative care delivery programs slowly began to be developed. In 2007, the Patient-Centered Medical Home Model was endorsed by primary care physician associations, and by 2012, forty-seven states had developed programs. This led to the need for case managers who were embedded at the point of care in the clinics, instead of being located remotely in health plans or call centers. By 2017, according to a survey conducted by the Health Intelligence Network (HIN), two-thirds (66.13 percent) of all respondents said they used ECMs within care sites. Research studies over the years have shown that ECM programs that adopted truly integrated, collaborative care models are very successful. So, let’s look at what makes these programs successful.

Goals and Objectives

The goals of an ECM programs should be long-term, primary outcomes that an organization wants to achieve. A program may start by identifying the Triple Aim as key goals: to improve the entire patient experience, improve the health of populations, and reduce the per capita (per person) healthcare costs. They may then add other, more specific organizational goals, e.g., to effectively manage high-risk patients for complications; to improve quality of care and quality of life; to improve patient outcomes; or to foster closer relationships between the physicians and the health plan.

Objectives are then developed to provide actionable, measurable steps that will be taken to meet the goal. They are measured using timelines, budgets, performance measures, and quantifiable resources. Examples include:

• The patient experience goal should include specific objectives to identify and measure all aspects of care, education, decision-making, treatment modalities, quality, satisfaction, and outcomes for the entire experience.

• The goal of improving health of populations may go beyond the health system itself and encompass the entire healthcare community, e.g., the involvement of local and national governmental agencies, non-healthcare community organizations, etc. They usually consist of four key objectives that answer "How much of what, will be achieved by whom, by when?"

• The goal of reducing the per capita cost of healthcare needs to include objectives that define the cost reductions, but they should not focus just on cost savings. They should identify and measure cost reductions, as they relate to the value received from the money invested. What measurable value-based benefits are obtained as a result of the cost reduction? Organizations may be allowed to use the cost savings elsewhere to enhance the overall experience.

• Other specific program objectives may include:

               o Identifying and improving value-based care initiatives

               o Improving Transitional Care programs

               o Providing more care to more people in real time

               o Reducing unnecessary utilization of services, e.g., admission/readmission to acute care facilities, length of stay in acute and sub-acute facilities, unneeded treatments and procedures; urgent/emergent care visits; duplication of services

               o Assuring follow-up office visits are obtained within 30 days of hospital discharge

               o Assuring at least 2 office visits/yr. are scheduled and kept for certain chronic conditions

               o Eliminating gaps and fragmentation in care

• The Six Aims for Improvement (safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity) should be considered for inclusion in all goals and objectives, as appropriate.

Strategies:

In order to achieve objectives, clearly-defined strategies (policies or specific action plans) need to be developed. Strategies are determined by analyzing a program’s strengths, weaknesses, opportunities, and threats and then using that information to build appropriate strategies that outline the steps that need to be taken to achieve each objective. Strategies usually answer "how" and "what" will be done and how objectives will be measured. Keep in mind that strategies need to be reviewed frequently because protocols and processes continue to evolve, which means the strategies need to evolve also.

Examples of strategies may include:

• Using cost savings in other ways to enhance the overall experience

• Avoiding complications that lead to admissions/readmissions

• Controlling disease progression through education and patient engagement

• Monitoring and managing variances

• Streamlining processes to improve productivity and workflow efficiency

• Improving access and use of appropriate services

• Increasing home visits to assess patient and environment

Operational Challenges

As beneficial as ECM programs are for patients, providers, office staff, health plans and the ECMs themselves, they do present challenges. Setting up an ECM program takes a lot of time, effort, and planning. It is not as easy as just placing a CM in the office. The ECM needs to be totally integrated into the office and work as a collaborative partner and valued member of the team. Yet initially the staff may not "buy-in" to the ECM program and may consider the ECM as an "outsider." ECMs can also be seen as just another member of the staff and asked to help with office functions when it gets busy. This could interfere with the ECM being able to complete the tasks he or she is responsible for. To alleviate this, the ECM’s roles and responsibilities need to be clearly defined and discussed with the office staff at the beginning of the implementation. This will allow the ECM to stay focused on CM functions and, in turn, alleviate some of the tasks that the office staff used to perform. Soon the staff will wonder how they ever got along without the ECM.

To create buy-in the office staff need to be intimately involved in the development of the program including its goals, objectives, strategies, expected outcomes, operational policies and procedures, patient engagement strategies, and reporting. In order to do this, relationships need to be developed with the office staffs in management, administration, nursing, customer service, utilization management, finance, and provider networking to learn and understand their key activities and operational procedures. The same type of partnerships also need to be made in the surrounding medical community that work closely with the office, e.g., home health, sub-acute facilities, rehabs, nursing homes, hospitals, pharmacies and other community agencies. All of these things take time and effort, but it helps ensure cooperation and buy-in from the office staff.

This chart from the Health Intelligence Network’s 2017 Healthcare Benchmarks report shows the ECM challenges reported by 78 organizations in the HIN survey. Another challenge not on this list, but often discussed, is the difficulty in finding an available office for the ECM. Another challenge for the ECM is the difficulty in having to learn multiple computer platforms. Providers and office staff may also have initial concerns about having to redesign and standardize their workflows, but once the program is operational, they realize the standardization helped to make the processes much easier and less chaotic.

Success Factors and Lessons Learned

Over the years, as ECM programs have evolved, we have learned what works and what doesn’t. These are some of the success factors and lessons learned from organizations who have implemented ECM programs.

A Geisinger Health System presentation entitled Embedded Case Manager given at a Medical Home Summit provides a good overview of their program including the rationale for their program, goals and objectives, tips on operational needs, CM functions, key attributes of choosing the right ECM, a detailed discussion of their 6-8 week orientation plan, and a discussion of their training and preceptor program.

Choosing the right case manager is a critical component of any program, so let’s look at some of their suggestions.

• A candidate for an ECM position must be a good fit for the office, so the providers need to be involved in the selection process.

• Prior CM experience is not a requirement, but experience in an office practice, home health or community nursing is helpful. The ideal ECM should:

                o Be autonomous, self-motivated, personable yet self-confident, supportive, empowering, highly organized, an independent thinker, and a passionate patient advocate

                o Be able to handle complex issues, drive outcomes; shift focus easily, multi-task yet still remain on task; work well with others

                o Possess these essential skills: interviewing, assessment, communication, active listening; problem solving, relationship-building, critical thinking, patient engagement, time-management, negotiating, and conflict resolution.

                o Feel comfortable reaching out beyond the health system and working with other outpatient and community organizations that can help the patient and/or family.

An ECM must be able to think out of the box! You often don’t find an embedded case manager – you create one!

• Geisinger also found that it is important to maintain ongoing communication with the embedded CM. Monthly meetings should be conducted with each ECM to: review cases and documentation; evaluate the program’s goal and objectives; discuss provider and staff interactions and relationships; discuss problems and opportunities for improvement; discuss management of gaps in care; review performance, productivity, and caseloads; and review programs outcomes, e.g. reduced readmissions, utilization, patient engagement, and patient follow-up visits.

Designing the Role of the Embedded Care Manager, is an article that discusses the framework for designing an ECM program and implementing ECMs into a physician practice. The authors looked at four early adapter organizations to determine the key elements of each program and to identify

Lessons Learned:

• Four critical components for implementation are: identifying physician champions; redesigning patient workflows; developing multi-disciplinary care teams that work to engage patients in their plans of care; and using EHRs that have robust data-reporting capabilities.

• A well-executed implementation plan is essential.

• The staff should be allowed to participate in the redesign of their responsibilities and workflows.

• The ECM's roles and responsibilities need to be clearly communicated to the team.

• The ECM should be the central point of contact, thereby eliminating redundancy and confusion.

• Most importantly, the role of the ECM needs to be communicated to the patients. They need to understand that they are not only a care manager, but a patient advocate and another resource for the patients and their families.

The article also discussed Success Factors:

• Care coordination takes time, effort, and financial resources, but is worth it because of the support it provides to physicians, patients, and families.

• Training and processes need to be redesigned with emphasis on communication, coordination, collaboration, and accountability.

• Continuous improvement should be an ongoing initiative.

• Program strategies, policies and protocols need to be reviewed at least once a year to assure they still conform to the program goals and objectives. Protocols and processes will continue to evolve, so strategies need to change also.

• Specific issues and gaps in care should be analyzed and reviewed to determine if changes need to be made to the program.

• An organizational change of this magnitude requires a cultural transformation.

The most important success factor is the Embedded Case Manager!

For those who want more detailed information about Embedded Case Management, the following articles and resources also provide valuable information:

• Collaborating for Care: Initial Experience of Embedded Case Managers Across Five Medical Homes: A 2014 article that compares 5 Medical Home programs before and after the use of Embedded Case Management.

• Case Study: Aetna’s Embedded Case Managers Seek to Strengthen Primary Care: An article that describes Aetna’s early adapter pilot study. While it is dated, it offers good insights into ECM.

• Embedded Case Management in 2012; A Health Intelligence Network (HIN) report that presents the results of the survey.

• Evolution of Embedded Case Management: A complimentary 2011 HIN e-book. It is dated, but describes industry ECM benchmarks and explains early adapter programs implemented by Geisinger Health System, Bon Secours Health System, Capital District Physicians’ Health Plan, and Lutheran Medical Center.

• A HIN blog with a list of links to articles dealing with Embedded Case Management.

• A HIN list of blogs listing 33 articles that are tagged with "Embedded Case Management."

The healthcare industry has made great strides in attempting to transform itself since the introduction in 2001 of Crossing the Quality Chasm: A New Health System for the 21st Century and the introduction of the first pilot Embedded Case Management program in 2007. The number of ECM programs have grown and will continue to do so, as the industry continues to move from volume-based reimbursement to value-based care. This industry-wide organizational change has created a cultural transformation that is predicted to lead to a more patient-centered team approach to care management. It seems that organizations and individuals have begun to embrace these changes, since the results and outcomes have been very positive. However the changes are not finished yet, so we need to continue to monitor the healthcare transformation. It is reassuring to know that case managers are in the midst of this industry-wide transformation, because case managers are capable of doing anything and they do it well.

Pat Stricker, RN, MEd, is senior vice president of Clinical Services at TCS Healthcare Technologies. She can be reached at pstricker@tcshealthcare.com.