CMSA Today - Issue 8, 2013 - (Page 18)

CMSA ACOs Moving Toward Longer-Term View Preparing Patients for Their Journey Ahead Coordination is key in case managers' evolving roles in caring for patients with disabilities BY KAREN HERCULESDOERR, MBA, BSRT, DIRECTOR, COMMUNITYBASED REPRESENTATIVES, ALLSUP T here has been a dramatic increase in accountable care organizations (ACOs), with many current counts identifying more than 100 Medicare-based entities in operation. When we expand our view to include Medicaid and commercial payers, the number of ACOs in 2013 exceeds 400. The most rapid number of expansions has been on the West Coast and Northeast, although consistent private-sector expansion continues to be seen in the Midwest. The prolific expansion of private-sector ACOs demonstrates the important role employers, payers, and providers have taken to rein in rising health care costs. Unfortunately, along with the rising incidence of younger individuals who have chronic illness, this expansion includes an increased frequency of disability. The goal of an accountable care organization is to lower health care cost, improve quality of care, and improve the overall experience of care being provided. This process happens in part through better coordination. Coordinated treatment systems that avoid duplicative services and lower the rate of medical errors show promise as one way to deliver high-quality, affordable care. A key component of ACOs includes shared benchmarks and financial incentives for all participating entities. This one component is a game changer, as now it is everyone's responsibility and incentive to make sure patients are adequately screened for services and to ensure that the proper payment mechanism is in place. patients who meet criteria but are identified as having significant utilization and costly provision of care. I have heard many in the health care community state that there is a real lack of understanding between the expansion of these new programs and benefit options with day-to-day management of patient care. Both issues might be addressed by having a good understanding of different types of ACOs, their focus or clinical specialty, and expanding the current case management processes. One way in which the expansion of case management services may be extended is to take a longer-term look at patient needs and clinical progression, while including a robust evaluation that is more outpatient and community focused. These evaluations must address specific and current clinical, financial, and psychosocial needs while anticipating secondary planning as a patient's financial circumstances and health insurance coverage changes. Professional case managers are perhaps most aware of the gaps in non-coordinated care that can hamper recovery. CASE MANAGERS' ROLE IN COORDINATION: THEY KNOW THEIR PATIENTS EYEING PATIENT CONCERNS WITH GAZE ON LONG TERM Some advocacy groups have expressed concern that ACOs may screen out eligible These gaps can become "opportunities" to demonstrate our expert case 18 CMSA TODAY Issue 8 * 2013 management and discharge planning skills. We are trained to identify issues and provide solutions. However, events don't always occur in the time or manner in which we had hoped. We provide patient resources to start the process that will assist them in receiving utility assistance. We counsel a family on how to start dealing with a life-changing illness. In the grand scope of things, we have to admit our shortfalls and recognize that many times we have taken the short view in order to expedite transfer or discharge. ACOs may offer the vehicle necessary to hold all entities responsible for delivering expert care in the lowest cost environment while proactively assisting the individual in managing complex disease process and lifestyle choices. Case management and social work are front and center to a strong foundation for ACOs to build upon. This requires all of us to take a longer, more comprehensive look at patient needs and patient education regarding their particular health condition and financial resources. PATIENTS WITH CHRONIC CONDITIONS: WHEN DOES IT BECOME A DISABILITY? Often overlooked is the need to have a meaningful discussion about how and when someone recovering from a serious injury or illness may have to file for disability benefits. Many patients don't seek assistance when they should, waiting until their condition has progressed to a dangerous point.

Table of Contents for the Digital Edition of CMSA Today - Issue 8, 2013

Where Was Care Coordination?
Preparing Patients for Their Journey Ahead

CMSA Today - Issue 8, 2013