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

The case management profession has changed dramatically in the past 25 years. In the late 1990s, case managers primarily worked in acute and post-acute facilities, health plans, medical management organizations and workers’ compensation companies. That began to change in the early part of the 21^st century with major changes that occurred in the healthcare industry. More emphasis was being placed on finding ways to deliver more efficient, quality care that was also more cost-effective. Healthcare was moving from a fee-for-service payment system that was based on the quantity and volume of services to a value-based system that was based on the quality and value provided by those services. New care delivery models and healthcare reforms, brought about by the Patient Protection and Affordable Care Act, meant that new innovative ways of delivering care needed to be developed. This certainly helped to spotlight case managers and the value they could bring to these programs.

The Case Management Society of America played a big part in promoting the practice of case management at the highest levels of government and the healthcare industry. Our leadership has effectively worked with local and national government agencies for years to educate them about the importance and value of case managers. This has resulted in an increased recognition and appreciation for our role and, in turn, has led to newly developed programs requiring case managers. These care coordination, transition of care, and case management programs help to assure that the value-based Triple Aim for optimizing healthcare system performance (better care, better health and lower cost) is achieved.

Case managers are seen as a critical component in these new care delivery systems. They are recognized as valued care team members who are able to provide clinical expertise and outcomes, care planning, quality care, and cost-effective outcomes while helping educate and navigate patients and their families through the increasingly more complex healthcare system. The number and types of roles and responsibilities of the case managers have been significantly enlarged, making them sought after in other care delivery areas, such as: primary care provider (PCP) offices, clinics, outpatient facilities, care organizations, hospital admissions, emergency departments (EDs), long-term care facilities, nursing homes, community clinics, employer work sites and government programs like the Indian Health Services and the Veterans’ Administration. This has caused the need for a significant increase in the number of CMs in these non-traditional areas.

Defining Embedded vs. Co-located

In 2007 the major primary care physician associations developed and endorsed the Patient-Centered Medical Home care delivery model that is focused on providing care that is comprehensive, patient-centered, coordinated, accessible, safe and of the highest quality. By 2012, forty-seven states had developed medical home programs. This led to a significant need for "co-located" or "embedded" case managers in physicians’ offices and clinics. The word "co-locate" is defined as: "to locate 2 or more things together; to place close together to share common facilities." Co-locating case managers in an office or clinic provides the ability for better communication and coordination; however, it does not, in and of itself, assure an atmosphere of integration and collaboration that elicits the concept of working as a member of an integrated, collaborative team in order to share knowledge, principles, and care plans to help patients meet their goals. The term "embedded" is defined as: "to make something an integral part of; to attach (someone) to a group for the purpose of advising, training, or treating its members." This definition goes further to describe the embedded CM concept and the CM’s close relationship or attachment to the group. "Embedded" more adequately describes the case manager’s role in becoming a truly integrated member of the group and a collaborative partner. Research studies over the years have shown that programs that have adopted truly integrated, collaborative care are significantly more successful than those who merely "co-locate" their case managers.

Statistics on Embedded or Co-located Case Managers

The rise in these programs has led to an increased need for additional case managers (CMs), especially in non-traditional areas like PCP offices, EDs, hospital admission departments, etc. Surveys conducted between 2012 and 2017 by the Healthcare Intelligence Network substantiated this embedded movement into non-traditional areas.

• The number of CMs in organizations continues to grow - from 88 percent in 2013 to 94 percent in 2017.

• In 2013, respondents said they had CMs embedded or co-located in 54 percent of their care sites. (Care sites include some of the other areas noted above).

• By 2017, two-thirds (66.13 percent) of all respondents said they embed or co-locate CMs within care sites. Hospitals had the highest number of embedded or co-located CMs (77.78 percent), while health plans reported 50 percent.

• In 2011, only 14 percent of CMs were embedded or co-located in PCP practices. That number increased to 47.5 percent in the 2017 survey.

• The 2017 survey also found that the top 3 sites for all embedded or co-located CMs were EDs and PCP offices (47.5 percent each), and hospital admission departments (30 percent).

                - Hospitals reported more embedded CM in the EDs (85.71 percent), but fewer in PCP offices (35.71 percent) and hospital admission departments (28.57 percent).

                - Health plans reported 4 sites that were equally distributed at 25 percent each: PCP offices, hospital admissions, a mixture of PCP office/home/hospital/etc., and other.

• In addition, 38.1 percent of respondents in the 2017 survey said they plan to add to or implement embedded or co-located programs within 12 months. The greatest interest was shown by health plans (75 percent), while only 25 percent of the hospitals said they had such plans.

Embedded CM Roles and Responsibilities

The goals of embedded case management programs are to effectively manage all aspects of care for high-risk, high-cost, complex patients, while also working to reduce hospitalizations and unnecessary costs, assure patient satisfaction and improve the patient’s quality of life. This will help achieve the value-based Triple Aim: improving the patient’s experience of care (quality and satisfaction), improving the health of populations, and reducing the cost of healthcare.

Programs tend to focus on specific objectives, such as:

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

• Assuring at least two office visits a year are scheduled and kept for certain chronic conditions

• Reducing the number of hospitalizations by avoiding complications

The embedded CMs are not only located in the office, but they need to be closely integrated into the care team as an integral part of the collaborative team. This integration is an essential and critical part of the orientation process for both the CM and the office team members. The CM cannot, and should not, be counted on to be another member of the staff when the office is busy. The CM must focus on her/his roles and responsibilities in order to be effective.

The roles of the embedded CM are similar to other CMs working in hospitals, health plans, medical management organizations, etc. They are responsible for conducting in-depth assessments; developing care plans; assisting with medication compliance and adherence; educating patients and family members; helping patients manage their goals and plan of care; monitoring patient outcomes; coordinating referrals; identifying gaps in care by reviewing claims, prescriptions, and lab results; managing admissions, discharges, and transitions of care; managing post-discharge follow-up calls and visits; addressing safety and quality issues; monitoring variances in care; and conducting patient care conferences with providers and other members of the collaborative team.

Embedded CMs have the unique opportunity to manage a patient through the entire continuum of care, rather than just handling recurring episodes of care. This longitudinal management and ongoing partnership with the patient and family allows the CM to get intensely involved to help empower patients to manage their own healthcare.

Program Results

A review of embedded CM programs has shown that many have been very successful:

• A 2010 Aetna embedded CM program resulted in a 43 percent reduction in the number of acute-care days, exclusive of denials. This was a 12 percent increase over the 31 percent they achieved in 2009 without the embedded program.

• Aetna’s Provider Collaboration Program conducted at 2 sites demonstrated reductions in: acute admissions (-30 percent and -44 percent), acute days (-33 percent and -50 percent), sub-acute admits (-14 percent), sub-acute days (-15 percent) and readmit rates (-41 percent and -55 percent). ED rates increased by almost 12 percent, but this was a result of proactive care to prevent admissions.

• Another Aetna study involving 3 provider groups with Medicare Advantage patients compared acute admissions per 1000 against those of the Centers for Medicare & Medicaid Services (CMS). The 3 groups demonstrated reductions of -46 percent, -48 percent, and -63 percent compared to CMS.

• An AmeriHealth study, using informatics and embedded CMs, demonstrated a 17 percent reduction in hospital admissions and a 37 percent drop in inpatient lengths of stay.

• A Geisinger Health System study, using embedded CMs in a PCMH model resulted in a 53 percent reduction in avoidable hospital readmissions, a 25 percent reductions in acute hospitalizations, and a 23 percent reductions in length of stay.

• A Sentara Healthcare System study demonstrated:

• 17 percent reductions in ED visits
• 48 percent reductions in all-cause inpatient admissions
• 21 percent reductions in all-cause readmissions
• 17 percent reductions in total cost of care
• Nearly double the number of 7-day follow-ups (patients followed by a CM had a 98 percent rate, while the average rate was 49.5 percent)

In addition to the positive statistical results achieved in the studies, the health plan programs that provided embedded CMs to the PCP offices also received very positive feedback from the participating physicians. The physicians felt the programs saved them and their office staff time by having the CM perform tasks that the office staff previously didn’t have the expertise or time to perform. They felt confident that follow-up tasks and recommendations would be completed by the CM and looked forward to updates from the CM on their patients’ progress. This relationship with the CM also fostered a closer relationship between the physician and the health plan, allowing both of them to meet their mutual goals. These types of programs changed the way processes were done and improved workflow and efficiency, so value-based care could be more easily achieved.

Embedded case management programs continue to grow each year. More and more innovations are being used to make these programs even more effective. This is a definite plus for the case management profession and for the healthcare industry as a whole. These programs fit perfectly into the evolution of moving the volume-based reimbursement system to a value-based system because it advances the Triple Aim of improving the patient’s care experience (quality and satisfaction), improving population health management strategies, and reducing the overall cost of healthcare.

Congratulations to case managers for being a critical component of value-based care delivery!

NOTE: Next month, for the August newsletter, we will take a more detailed look at the goals, objectives, benefits, challenges and success factors of embedded case management programs.

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