By Michael J. Randall, MHA and Patricia A. Hines, Ph.D, RN

While the nature of the healthcare reform debate changed in recent weeks, the direction in which healthcare delivery systems need to move remains clear.  Healthcare spending is out of control, and despite efforts, quality remains variable and somewhat elusive.  A variety of new payment mechanisms (e.g., Bundled Payment, Acute Care Episodes, Medicare Physician Group Practice Demonstration, and Bridges to Excellence®),are currently being piloted by Medicare and others.  One mechanism that integrated delivery systems are using to change culture, align incentives, and improve care delivery processes and clinical outcomes is clinical integration.  Clinically integrated organizations implement robust infrastructures and mechanisms (e.g., provider and patient portals, real time reporting and alerting, electronic health records, care management, clinical measures and protocols) to improve quality and reduce cost through collaboration with physicians. 

In clinically integrated organizations, the traditional functions of utilization management and case management evolve to more seamless and coordinated care, with a focus on the multiple venues of care, health maintenance, the patient’s role in care, and the management of chronic diseases.  Here are the top 10 initiatives to assure that your care management function is fostering clinical integration and assuring success in new payment models.

1.  Advanced Practice Roles. Clinical care managers with a specialty in primary care and general medical surgical care will take a larger comprehensive role in coordinating care across inpatient and outpatient settings, especially for patients with chronic illness and co-morbid conditions. Given that nurses must meet National Committee of Quality Assurance (“NCQA”) and MedPAC standards of care, including coordinating and integrating care standards, nurse practitioners can play an important role as primary care providers in clinical integration. It is estimated that 83,000 nurse practitioners are currently providing primary care services, with significant responsibilities in managing chronic conditions and promoting use of primary care services). These individuals will serve as a conduit for linking wellness, the management of chronic diseases in the outpatient setting, inpatient care delivery, and post-acute services.

2.  Communication. Silos within the hospital and across the system must be removed and care needs must be organized around the patient. Care managers are an important linchpin in assuring communication with and among hospitalists, “SNFists”, and other physicians in coordinating care both in and out of the hospital. Care managers in organizations that are clinically integrated will assume additional responsibilities, including negotiating with health plans, collaborating across multiple disciplines and care settings for optimal outcomes, and engaging community resources for care delivery.

3.  Clinical and Quality Transparency and Pay-for-Performance. Performance will have a significant impact not only on payment for services rendered, but also on any incentives the hospital and physicians may earn for demonstration of quality and cost reduction. Care managers in clinically integrated organizations must play a leadership role in identifying risks and developing performance improvement initiatives that are multi-disciplinary and lead to measurable results.

4.  Strong Medical Staff Relationships. Nurturing strong physician relationships will be an essential skill set for care managers as they assist in the care coordination across specialists and care settings. While care managers will fill the essential coordinator role in clinical integration across clinical specialties to realize operational and strategic goals, patient satisfaction, and optimized revenue, physicians must be engaged and own the process. Care managers are in a key position to partner with the medical staff, create a platform for seamless care coordination, and provide them with the tools and support they need to be successful.

5.  Human Capital Changes and Challenges. The trend for increasing utilization of hospital-based physician specialists (i.e. hospitalists, intensivists, laborists, and surgicalists) will continue, which is a challenge from a coordination of care perspective, but also offers some opportunities. By working closely with these specialists, organizations can more easily influence the appropriate utilization of services through the use of care protocols and efficient care processes. Care must be delivered in the appropriate setting, and systems that will ensure a smooth hand-off must be built to manage the transition for the patient.

6.  Knowledge Management and Standardization. Clinical care protocols based on best practices have been sporadically utilized in the acute care settings for diagnoses that reflect the majority of admissions. In many organizations, adoption of these protocols is voluntary, resulting in variability in care practices. Metrics such as length-of-stay (“LOS”), ancillary utilization, and cost per case may not correlate to quality outcomes, hindering medical staff discussions of shared knowledge management and the necessity for clinical standardization. Care managers will leverage the information from electronic medical records (“EMRs”), data warehouses, and disease registries to provide information on quality and cost, and manage key populations of patients.

7.  Plan of Care. As hospital LOS declines, patients are being sent home earlier in their treatment and with continued care requirements. Existing discharge practices are often fragmented, have ineffective handoff strategies to ensure continuity of care, and frequently lack an immediate contact or appointment with the primary care provider. The patient may have a limited understanding of his/herdischarge plan for continued care and lack of medication compliance, which results in frequent readmissions. Healthcare reform will provide incentives for patients and their families to take a more active role as partners in their care delivery and decision-making. As health systems develop clinical integration strategies and become more at risk for the outcomes of the patient population under their care, care managers will work closely with patients to define treatment goals and write compliance contracts to facilitate adherence to treatment plans and follow-up care. Handoff communication is essential to ensure a complete and accurate transition of information from caregivers to the patient, family, and other care givers. Key data elements should include a discharge report that notes patients’ functional status, medical history, baseline information, learning needs, care plans, medication reconciliation, and services provided while admitted.

8.  Effective Discharge Planning. Reimbursement will be affected by the utilization of post-acute venues and the management of chronic readmissions. One model for more effective discharge planning is called the “Care Transitions Intervention” model, where a nurse-coach is responsible for helping patient’s transition back into the community and self manage their recovery. The coach visits the patient once in the hospital, once at home within 48 hours of discharge, and then calls the patient three more times to check on how care treatment is progressing. The coach focuses on four pillars: medication self management, a patient-centered record, primary care and specialist physician follow up, and the patient’s knowledge of adverse symptoms of his/her condition. Care managers will fill an essential role in the communication handoff and ensuring that the plan of care is understood and implemented.

9.  Information Technology. Care managers, physicians, patients, and others will have immediate access to advanced technology devices, such as mobile, tablets, and PC portals that will provide real time access and alerts and facilitate care coordination from home to home. EMR access will allow information exchange between sites of care and members of the care team. Telemedicine will become more widely adopted especially in the management of chronic disease, such as congestive heart failure.Telemedicine enables real-time data on a patient’s functional status while at home to be relayed to a healthcare professional who reviews results immediately and implements interventions before a patient deteriorates to a status that requires hospitalization. The data may be quantitative, such as daily weights and blood pressure, or qualitative, such as symptoms a patient may be experiencing. The results can be sent to a nurse or physician through a computer, PDA, or Smartphone. Care managers will evaluate the data in time and collaborate with the healthcare team to adjust the patient’s treatment plan.

10.  Performance Scorecards. To thrive in tomorrow’s payment model, hospitals and physicians will need to demonstrate value through improved outcomes and cost management to receive incentive payments. These include: 1) clinical process and outcomes (e.g., nurse sensitive indicators, core measures, management of hospital acquired infections); 2.) patient and caregiver perception of care (e.g., satisfaction rates, patient attrition) and 3) utilization and costs (e.g., bed-days, readmissions, one-day length-of-stay). An important tool for elevating performance is the use of scorecards or dashboards. Organizations should invest in advanced analytic and modeling capabilities to better understand the association between care processes, outcomes, and practice variability. Measurement, monitoring, and continuous improvement will be pervasive in clinically integrated organizations. Scorecards should exist at all levels of the organization, from executive and department directors to staff and physicians. All members of the organization must be aligned and strive for a common set of objectives, each armed with information that is within their span of control and influence.

Clinical Integration Care Management Team

For more information on the roles of care managers in a clinically integrated organization, please contact Michael Randall at mrandall@thecamdengroup.com or Patricia Hines at 310.320.3990 or phines@thecamdengroup.com.