by Stefani Daniels, Founder and Managing Partner
Published on Oct 08, 2018

Value based case management is achieved by shifting from managing tasks to coordinating care for selected patients. How to achieve this transformation requires dynamic leadership and a clear vision of the future.

As hospitals transition from volume to value, hospital executives continue to explore the many components of hospital operations that impact the efficiencies of patient care activities.  Evidence based guidelines are more widely being used to promote 'best practices' and eliminate potentially wasteful or excessive medical interventions and while process outcomes are still prevalent, more and more organizations are adding patient reported outcome metrics (PROM) to their quality scorecard. Outpatient services are rapidly expanding as alternate, and often safer, care venues to manage chronic medical conditions and hospital Boards and executives acknowledge that their mission has changed from providing acute care to keeping the community healthy and patients out of the hospital.  These changes are occurring so that the organization will thrive in a totally reformed healthcare system - one that rewards value over volume. 

It is generally easier to defend the status quo than to change it, and in this difference lie the roots of the dominant case management leadership response to the rapidly escalating changes in the current marketplace spurred on by the Affordable Care Act. However, evidence is mounting that the safety of the status quo is a sentimental illusion based on 1990s goals and expectations.  Some hospital case management leaders have begun to confront this issue directly and transformed hospital case management departments into care coordination programs.  They have realigned utilization review activities under the revenue cycle, and have supported the return of discharge planning to the patients' nurse and care team. They have worked with hospitalists to reduce the amount of unit-to-unit travel time and collaborated with their medical colleagues to regionalize coverage and design accountable care units; and they have centralized all campus care coordination activities to eliminate fragmentation and redundancies among various system providers. 

Changing the daily practice of hospital case management requires making changes in structure and processes which is, admittedly, a major challenge in many hospitals. But there are hospital case management leaders who are among the vanguard of change agents who want to preserve the integrity of their chosen field. These leaders have replaced handwringing with active engagement in transformation.  They've examined the current marketplace, looked ahead to future possibilities, recognized the need for new model of practice and took action. These are the individuals who recognize that leadership is not a position - it is action.  For others, it's very easy to blame circumstances or personalities or to point the finger at "them."  However one cannot simultaneously be a leader and victim.

I have seen courageous leaders take to the podium at department head meetings and explain the need for change and I have watched while savvy leaders re-oriented their case management team from completing tasks to achieving outcomes through pro-active advocacy which is, arguably, the case manager's primary ethical responsibility even when they have an obligation to other parties such as their employers or the insurers who are paying for provided services. I have sat in the Board room and listened to hospital case management leaders persuade the C-suite occupants - through persistance and an exceptional ability to describe the difference in practice models in terms that are personally meaningful to each member of the executive team - that case management change is essential, 

Care coordination has been identified as a key strategy for future success and was the original intent of hospital case management. Well designed, targeted care coordination that is delivered to the right people has been shown to improve outcomes for everyone: patients, providers and payers.Unfortunately, back in the late 1980s early 1990s, it was replaced by the consolidation of discharge planning and utilization review when executives realized that they were not prepared to withstand the financial free-fall brought on by the introduction of the prospective payment system.   We are reliving those days as hospital leaders realize that they may not be able to survive in the new payment landscape and dwindling patient volumes. Beckers reports that 11 hospitals have already closed in 2018 and 85 rural hospitals closed between January 2010 and July 2018,  

Over the last five years, value based care has made its way into the collective consciousness of the entire healthcare delivery system and executives are trying hard to keep pace with the speed of transformation to establish themselves as a  next-generation healthcare organization.  Hospital case management is not immune from the changes taking place. Changing the way hospital case management programs are structured and how case management is practiced depends upon leadership's appetite for innovation.  There is safety in the status quo, but there is also risk. 

Where do you want to be?