Healthcare Payor Strategies for Co-Located Case Management

Thursday, January 29th, 2015
This post was written by Cheryl Miller

How to best strategize the co-location of case managers at points of care? The key is to understand the population you’re serving, be very targeted, and direct your services appropriately, says Dorothy Moller, managing director in the government healthcare solutions business unit of Navigant Healthcare.

Question: New market data on embedded case management found that two-thirds of respondents have co-located case managers at points of care, including primary care practices, hospital ERs and patients’ homes. What are some payor strategies for matching case managers with providers, and how do health plans benefit from co-location?

Response: (Dorothy Moller) I must acknowledge the safety net payors, who have been co-locating case managers for a number of years — in particular in hospital ERs. Very often the case managers you co-locate are not healthcare case managers, but behavioral health or social services case managers.

In terms of strategies for co-location, it depends on the population you’re serving and what you’re trying to accomplish with that population. There are a number of places where you can co-locate case managers — not so much case managers as case or care coordination services. Very often in large multi-specialty or primary care practice settings such as federally qualified health centers (FQHCs), community clinics, or multi-specialty clinics, case managers are sometimes nurses, sometimes social workers, sometimes physician assistants performing various functions. They may link members with specific services that are non-health related or coordinate care.

The key is to understand the population you’re serving and to make sure you include case management and care coordination services appropriate for that population. If you have a very acute population with high risks or readmission or other health complications, clearly you’re going to have a different kind of co-located service and you’re going to place them in a different location than you would otherwise. If you’re trying to encourage more effective access of services, use of preventive services, use of nurse call lines, and so on, you might place those services in a primary care practice. Those are going to be very different.

Embedded case managers could even be community health workers. In fact, I’ve worked with payors in the Southwest using community health workers in that role. They are sometimes co-located within the practice but then go into the community and deliver education services there as well, sometimes in collaboration with medical and education specialists.

It depends on the population you’re serving, the types of services you want to encourage or direct members to, and the most efficient staffing model for those services. Ultimately, you must remember you’re trying to develop a better staffing pyramid within the practice so that physicians do the most complex work — where a physician’s skills and capabilities are most needed. Nurses and other staff deliver care and services appropriate for their skills, education and capabilities. Be very targeted, understand your population, and direct the services appropriately.

healthcare trends
Dorothy Moller, MBA, is a managing director in the Government Healthcare Solutions business unit of Navigant Healthcare. She has nearly 30 years of experience specializing on a wide range of strategic issues from business intelligence and competitive analysis, to market, business and product strategy and design, business and product innovation, and business and operations turnaround and repositioning.

Source: Healthcare Trends & Forecasts in 2015: Performance Expectations for the Healthcare Industry

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