How case managers can succeed in value-based care

Better quality patient care is the goal of the new order of value-based care, and it’s an important mission of which most patients and providers agree upon — in theory. Realistically, this shift in vision and in the way care is managed delivers great challenges and case managers in particular are feeling the pinch of these growing pains.

Case managers already juggle a host of responsibilities, as they work tirelessly to steward patients on the better road to recovery. Therefore, the additional administrative responsibilities and pressures to drive value can be overwhelming. So how can case managers receive the support they need?

With over 50 years of collective clinical nursing experience with a case management care transition focus, naviHealth Senior Director of Clinical Advisory Services, Cheri Bankston, and Senior Clinical Advisor, Linda Keller, share their expert insights on this hefty transition — and how to leverage the opportunities these challenges present.

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The Landscape: Changes, challenges and opportunities

Perhaps, one of the most significant changes in the march toward value-based care is the need to look at the patient’s care beyond the four walls of a hospital — and not just limited to the patient clinical episode itself.

Bankston describes this longitudinal care approach as both a blessing and a curse. The upside being a team approach to coordinating care for patients across multiple providers and community networks, with everyone being invested in better patient outcomes. This requires a well-defined communication plan that easily shares information across all teams and settings.

“You now have to take in to consideration the post-acute care (PAC) provider, the primary care physician, community-based providers, caregivers and more,” says Bankston. This concept rolls heavily into BPCI Advanced too, as the model demands provider collaboration to thrive, even beyond the 90-day clinical episode.

As systems move toward this increasingly collaborative initiative, Keller’s experience leads her to believe that a case manager is likely to encounter an “uphill battle” as we continue to work with providers straddling different reimbursement models.

“For the many providers who are still getting paid for days in the hospital and tests administered, the concept of everyone now being paid from the same bucket, while still driven by patient outcomes is somewhat foreign to some,” Bankston adds. “Now, we’re asking people to think differently about a focused population, not just thinking differently about all of their patients. These pockets of change make system change more difficult.”

So how can providers effectively navigate these challenges of change?

According to Bankston, it starts with a basic understanding of value-based care and spreading that knowledge out to the case management team.

“The team really needs to feel empowered to say ‘okay, we can do this’,” says Bankston. This level of change management requires buy-in and a common vision for patients, both within and beyond the hospital system, adds Keller.

Shifting the focus to quality and patient-centered care is exciting, according to Keller, and while there may be some growing pains, Bankston believes it’s headed in the right direction.

“With value-based care, delivering better patient experiences and outcomes correlate to how we’re scored and reimbursed. Now we’re tying quality outcomes to how the patient is doing in their individual recovery journey across care settings,” Bankston says.

Tools and best practices for case managers to find success in value-based care

The increasing medical complexity of patients, the lack of community resources and the social determinants of health that are leading to readmission are all important pieces. Our challenge is to identify and take appropriate action on these patients before they leave the hospital.

When a patient is discharged, there are many factors to consider that impact their recovery: medication reconciliation, having the right caregiver at the bedside (one who is both educated on providing the care that’s needed and able to meet those needs), the ability to pay for medications and get to follow-up appointments, food security, medical equipment and many more. As a result, patients can fall through the cracks at this stage and can be at an increased risk for readmission.

This transition post-discharge offers an opportunity and perhaps, critical need, for patients and their primary caregivers to partner with the case manager through the whole care journey — not just during the hospital episode.

Bankston and Keller point to other tools and best practices for case managers to succeed in value-based care:

1. The integration of clinical decision support technology into a post-acute care (PAC) discharge and care transition workflow: Case managers can leverage available predictive technology to make sure that the patient transitions to the best post-acute care setting available based on their needs to maximize quality outcomes.
   
2. A reliable, connected and engaged network of high-quality PAC providers based on data-driven insights regarding quality outcomes, efficiency and operational effectiveness: According to a Stanford University study, 70% of health care spend is in the PAC market. To better manage that spend while upholding patient choice, case managers must engage and educate patients and their caregivers in their care decisions regarding providers by offering them a number of quality options.
   
3. Robust and real-time reporting and analytics to track performance, identify trends, and drive continuous improvement: It’s all about concurrent management of patient and caregiver goals throughout the care journey.
   
4. Active engagement of the patient and family post-discharge across the care continuum beyond just ‘checking the boxes’: This practice involves a two-way conversation, not just “handing someone a printed discharge plan,” says Bankston.
   
   Alignment and consensus across health system leaders, hospital-based providers and case managers that driving value is a priority: “We have to be able to answer the question ‘why are we doing this?’ It’s not just about reimbursement, we all have to step up and make this change work, because value-based care, or rather, better care, is what we’ve always wanted for our patients,” says Bankston.

The necessary steps taken by case managers to balance quality outcomes for their patients will be rewarded in value-based care. As difficult as the shift to value-based care is perceived, it can only be successfully managed if the ultimate goal continues to be the patient. Gathering the necessary information while successfully communicating the needs of the patient will be as impactful as ever.

“In value-based care, case managers are using the information obtained during the assessment process to make an enormous impact on guiding patients to achieve optimal recovery,” says Keller. “Though this may feel like a tremendous responsibility and challenge, equipped with the right combination of technologies, skills and tools, case managers can significantly transform care across the continuum to better serve patients.”