Care Management in a Value Based Marketplace

by Stefani Daniels, Founder & Managing Partner
Published on Oct 25, 2016

The value agenda for care management will require restructuring how care management is practiced in the hospital. It will require thoughtful preparation about how practice is organized. And it will require methods to identify patients who need additional support for the journey through the continuum of care. The overarching goal for care managers, as well as for every other stakeholder, must be improving value for patients, where value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes. Improving value requires either improving one or more outcomes without raising costs or lowering costs without compromising outcomes, or both. Failure to improve value means, well, failure.


As healthcare transformation kicks into high gear, hospital leaders are stepping up efforts to rein in costs, boost quality and improve care coordination across the continuum. Even as hospital execs have one foot in the traditional FFS world, they know that at the same time, they have to gear up and create, in many cases, entirely new care management programs for a value-based world. 

Many hospitals are still practicing a task oriented, 2nd generation functional model.  That means that their care managers have assumed the role of discharge planners and logisticians. And in some hospitals (though thankfully, the numbers are shrinking), those same discharge planners are also expected to be the utilization review experts to guard against payer exploitation. 

Several years ago, actually around the time of the IOM report, To Err is Human in 1999, progressive executives and case management leaders recognized that to keep up with the changing marketplace and the call for better outcomes, case management programs had to change too. That's when 3rd generation models began to appear with case managers positioned as members of the care team to facilitate progression of care for high risk patients and coordinate the post acute care for those patients with community providers. Case management leaders were instrumental in urging hospital partnerships and/or affiliations with community providers to ensure a seamless transition from acute care to community care.  Those 3rd generation programs proved their value very quickly by generating sustainable bottom line results both clinically (lower complication rates; greater adherence to evidence based protocols, etc) and economically (lower resource utilization per case; reduced denials, etc).

With the emerging value based market, hospital based care management program leaders have sharpened their goals once again and we’re into the era of 4th generation continuum of care models. The pace of transformation remains spotty and some organizations are well into their transition to value based care while others remain grounded in the volume based world.  But those who are preparing for the Ian Morrison leap from curve 1 to curve 2 have care managers using predictive analytics or other early risk factor identification methods to detect high risk patients and are encouraged to zero in on obstacles to progression of care such as delays in treatment or expediting referrals to specialist services such as palliative care or psychosocial counseling.  They use comparative physician practice data to coach their medical colleagues - generally hospitalists - according to evidence based protocols or standard order sets, and are urged to help physicians rein in excess resource utilization through real-time conversations about the value of repeated, wasteful, or potentially harmful interventions.  And they attend the early morning hand-offs rounds with their medical and care team colleagues to establish the ‘plan for the day,’ set priorities, minimize physician intrusions, and expedite progression of care. 

But most of all, today's contemporary care managers have adopted a value based mindset and have incorporated considerations of cost awareness and risk benefits into their practice to protect the multiple stakeholders in the healthcare game.  The process of value migration doesn’t happen randomly but is a planned process combining quality, safety and financial dimensions into the care managers’ orientation.  It requires adventurous leaders who understand the next generation care management models and how to create value in the new healthcare marketplace and use scorecards to objectively quantify the care manager’s contributions.  It requires combining population health strategies with a the standards of practice to enter into pro-active partnership with the physician, the patient, and the care team to co-manage care more efficiently and it requires better verbal communication to make sure care is connected seamlessly across the continuum to enhance the patient’s experience of care.  

The transition to value based care management requires a dedicated commitment to proactive advocacy among all care givers to protect the patient from avoidable clinical or financial risk; to promote the Triple Aim and;  to use that old saw, ensure that the patient receives the right care, in the right place, at the right time.