Emerging Fourth Generation Hospital Care Management

There are many goals of 4th generation, patient-centered, hospital care coordination including sharing information with the patient and family, help patient & family understand results and treatment recommendations, help patients choose specialists, share medical tests with other providers to avoid retesting, inform care team of any necessary accommodations that the patient may require, ensure that patients receive appropriate follow-up care and ensure smooth transition from one care setting to another.

In response to the shortcomings of traditional care management programs for the growing population of high risk patients with advanced illness, pioneering case management leaders have created new models to coordinate the treatment plan, unify fragmented providers and settings,and move the focus of care out of the hospital and into the home and community as soon as medically feasible. Under most current case management models which emphasize discharge planning and utilization review, high risk people suffering from advanced illness with multiple chronic conditions, declining functions and poor prospects for full recovery, very often fall through the cracks left by hospital case managers who spend too much time in the charts and on the phone.    

These innovators have mostly remained silent but they have designed models that reflect the 4th generation of hospital case management more commonly described as “Continuum of care' or population health models.  Some have even described these new models as value based care management.  These new programs create a seamless link between acute medical management of complex or chronic illnesses, transitional care for post acute management up to approximately 90 days, and community care for long term management.  Within each leg of the 3-legged pop health stool, the care manager serves as a navigator to promote appropriate use of related services including home care, palliative care, nursing home or rehab care, or any number of 'touch points' for the patient. Care managers working within these models make certain that intensive managemernt that may have begun in a hospital can continue if needed in the home or community.  Based on initial research being published, a continuum of care approach promotes good clinical outcomes, supports personal choice, prevents unwanted procedures and hospitalizations, and  reduces the costs of care.   

Through continuous interactions between the care coordinator and members of the care team for planning and shared decision making, continuum of care provides an avenue for the direct participation of high risk patients and family caregivers in developing their own unique, personalized care plan - oftened referred to as patient-centered care . These programs generally reflect an organization's pop health strategy and its commitment to continuity of care across the continuum.  Care managers, or whatever title given to the single consistent resource that works with the patients and the care team, may change as the patient moves from one "leg" of care to another.  But the transition is always seamless with person-to-person hand-off.  This integrated package of care coordination services is best reserved for the high need, high cost patients who need the assistance of a care manager the most. . 

Our current hospital care management programs have generally not done well in providing high need, high risk patients the broad levels of advocacy and coordinated support that they need to maintain independence at home or in the community.   If we don't start doing it now, someone else will.