Organized care and information sharing

by Stefani Daniels, MSNA, RN, CMAC, ACM
Published on May 06, 2016

In 40 different studies, there are 40 different definitions of care coordination as well as different terminology. Some organizations use care management, care coordination, and case management interchangeably. But they all seem to have singularity in intent and services. They all share a common set of activities to facilitate the appropriate delivery of health care services by marshalling personnel to carry out patient care activities; exchanging information among care team members; and developing processes through which appropriate, safe and cost effective medical and medically-related social services are identified, planned, obtained and monitored.

From the vulnerable elderly, those with multiple chronic or complex conditions, people receiving care in multiple settings with multiple providers, and patients taking large quantities of prescription medications, the spotlight is on care coordination. There is universal agreement that care management/care coordination (CM/CC) is essential to achieve the Triple Aim:  Improving the costs of care, the experience of care, and the quality of care, but to live up to its promise of improving the outcomes of care, patients deserve to receive these services from someone competent and knowledgeable.  

Case management in hospitals is a compilation of several services typically provided by the hospital.  It may, and often does, include CM/CC, utilization review, clinical documentation improvement, and psychosocial counseling services.  With each dramatic shift in the marketplace, these services often shift as well so that now more than 30% of hospitals have dedicated utilization review specialists working within the case management program or oftentimes, part of the revenue cycle reporting structure. Similarly, psychosocial counseling services in the hospital, long a role dominated by social workers, now include licensed clinical professional counselors with many specialities such as addictive behaviors, behavioral health, or family therapy.

CM/CC is widely seen as having the potential to address the systemic problems inherent in every acute care setting: Poor communication among members of the patient's care team; fragmentation of service delivery; excessive interventions; delays in treatment or services that compromises patient safety; and failure of care team professionals to work together to ensure that care is appropriate to the patient's needs and preferences.  

The National Quality Forum (NQF) has stated that CM/CC "is the deliberate synchronization of activities and information to improve health outcomes by ensuring that care recipients' and families' needs and preferences for healthcare and community services are met over time."  Thus the hospital care manager helps ensure that the patient's needs and preferences for care are understood, that the treatment plan reflects those needs and preferences, and that all are shared between providers, patients, and families as a patient moves from one setting to another.   

CM/CC deserves the attention it is now receiving but the question remains whether the intent of CM/CC is being fulfilled in hospitals across the country.  Care coordination does not consist of a well-defined set of processes but it should reflect the standards of care proffered by the professional organizations such as Case Management Society of America or the Amercian Case Management Association.  

We invite our readers to consider how care management is practiced in their facilities. In order to provide the best quality and most cost efficient care and treatment, the care team must engage in open dialogue in a mutually respectful; environment. Within this dynamic it is essential to promote cooperation and collaboration through the expertise of a care manager. If care coordination is to live up to its potential in hospitals, it must be the domain of professionals who are qualified to perform this service.  Without that expertise, care management will fall short of its potential and many of its patient-oriented  goals will become nothing more than broken promises in a fragmented delivery system.