Case Managers: Challenged by Controversial Reform Laws and Struggling Economy

Thursday, July 12th, 2012
This post was written by Jackie Lyons

The struggling economy and controversial healthcare reform laws are key issues that affect Americans on a daily basis. According to recent HIN case manager interviews, these trends will continue to affect the healthcare industry and case management as well. Case managers shared their concerns associated with the trends, as well as possible solutions to counteract them in the upcoming year.

“It is critical that we do not lose sight of what is happening with healthcare reform, and we must continually plan for the effects it will have on balancing patient outcomes through care transitions along with pay for performance and changes to provider reimbursement methods,” said Stacey B. Hodgman, MS, RN-BC, CCDS, CPUM, district director of case management for Kindred Healthcare and board of directors for the Case Management Society of New England.

Helen Schreiber, RN, BS, CCM, executive vice president of S&H Medical Management Services, Inc., agreed the economy will continue to impact the healthcare industry in the upcoming months. Creative program marketing is one approach for organizations to counteract this, Schreiber suggested.

Other case managers are also focused on the weak state of the economy. “I see healthcare becoming more challenging given the current socioeconomic turmoil in the nation and in the existing political arena,” said Miriam Weiss, MSN, RN, CCM, care manager at Amerigroup Corporation, care manager consultant at CareManagers Inc. “I also see the benefits of various programs under consideration, particularly, the medical home model concept.”

The concept of the medical home model resonated with other case managers as well. Managing care transitions and following patients more carefully are also key. Linda Conroy, RN, BSN, clinical integration case manager for Hartford Physician Hospital Organization (HPHO), plans to develop effective interventions to assist patients in managing chronic illnesses, and to break down silos within the hospital and in the community.

In relation to paying closer attention to patients and analyzing qualitative data, Barbara King, BSN, RN, co-founder and president of NurseValue, Inc., said, “Healthcare is trending toward benchmarking utilizing clinical treatment guidelines. Utilizing benchmarking tools to measure success will become increasingly important to the practice of medicine and nursing.”

According to Hillary Calderon, RN, senior manager of Corporate Case Management for HCA, in order to obtain better success metrics, an important trend to address is care coordination. “It is a must for healthcare to achieve better outcomes and cost containment,” she said.

As usual, cost is at the forefront of healthcare issues. “Money talks, and reimbursement has been the biggest challenge,” said Sonia Morrison, RN, CM, BSN, RN case manager at Salinas Valley Memorial Healthcare System(SVMHCS), Nurse Assessment Consultant and Educator for veterans at Visiting Angels of Santa Cruz.

In response to the monetary challenges of the past year, Linda Van Dillen, RN, BA, CCM, executive VP/Partner of S&H Medical Management Services, Inc., researched the top cost trends in workers’ compensation and modified the company’s services to assist the claims staff in making informed decisions as to reserving the claims and making recommendations to mitigate costs.

Barbara (Bobbi) Kolonay, RN, BSN, MS, CCM, owner of Options for Elder Care, Medical Care Management Services for Seniors, indicated that with medical reimbursement declining for readmissions of specific diagnoses, insurance carriers and hospitals should look into partnering with medical geriatric care managers. Kolonay said, “My clients are rarely admitted to the hospital. When they are, I follow them, and direct their care through the continuum.”

With all the changes in the healthcare industry brought on by healthcare reform and the changing economy, case managers suggest that the keys to success include focusing on care coordination and transitions, implementing the medical home model, mitigating costs and reimbursement, and utilizing benchmark tools to measure success.

For more strategies, and metrics and measures on healthcare trends, check out 2012 Healthcare Trendtracker: Real Data on Adoption, Outcomes and ROI, an 80-page concise snapshot of industry activity in ACA priority areas with dozens of benchmark tables.

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