Recognize value of certified case managers in managed healthcare

May 1, 2008

Case managers provide services at critical junctures, whether facilitating discharge from acute care to a sub-acute facility or coordinating home healthcare services for an individual to prevent hospital readmissions.

Case managers provide services at critical junctures, whether facilitating discharge from acute care to a sub-acute facility, or coordinating home healthcare services for an individual to prevent hospital readmissions. The value of case managers in the healthcare arena is well-recognized.

A prestigious group of professional case managers have obtained additional recognition as certified case managers (CCM). Certified case managers improve the cost effectiveness, timeliness, access, and quality of services delivered. According to the Commission for Case Manager Certification (CCMC): "Certification indicates that the case manager possesses the education, skills, moral character, licensing and experience required to render appropriate services based on sound principles of practice."

Through certification, case managers demonstrate that they possess the knowledge and skills to join the resources and team members to promote the right care in the right setting.

Certified case managers can make a direct contribution to help healthcare organizations to achieve goals such as improving adherence to specific indicators tracked by HEDIS (Health Plan Employer Data and Information Set).

Within the HEDIS framework, CCMs strive to promote patient self-management and adherence to clinical guidelines through better coordination of care between the patient, the physician, and the other members of the care team. Their efforts are essential to ensure that patients receive appropriate preventive, as well as curative treatment. For example, when working with patients with chronic conditions, such as diabetes or who have been diagnosed with cancer, case managers ensure that these individuals receive the appropriate evidence-based care, which will contribute to improved HEDIS scores for the managed care plan.

Another area in which case managers can contribute their expertise is satisfaction, specifically the NCQA's CAHPS. Among the many steps that can positively impact satisfaction, particularly for members, is timely access to care. Case managers focus on advocacy with patients by coordinating referrals for necessary services and clarifying benefit coverage issues. Members of health plans are usually delighted to have a case manager who can assist with those kinds of clinical and administrative issues with their health plan.

In addition, CCMs provide expertise handling complex cases. One example includes members with multiple co-morbidities who do not adhere to the treatment plan. The case manager can monitor the patient to promote follow-through with the care plan and physician's orders, and also encourage the individual to be prepared for follow-up visits with questions, concerns, or helpful information.

Case management promotes client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Through certification, case managers attest to their expertise in promoting patient-centered care. CCMs educate and empower individuals and their families about treatment, facilitate communication with physicians and other care providers, and present multiple care options.

The value of the patient-centered approach has been well-documented, especially for complex patients. These individuals who have clinically advanced illnesses and multiple comorbid states represent the most expensive cases in healthcare. Cases occur in 1 out of 1,000 in the commercially insured population, and may be five to 10 times higher in the Medicare population.

A study of 756 patients in a managed care plan in California, many of whom had life-limiting diagnoses with multiple comorbid conditions, found that those receiving "patient-centered management" experienced several favorable outcomes, including: