CMSA Today - Issue 2, 2011 - (Page 37)

CMSA Ask the Expert The Role of the Case Manager in Accountable Care Organizations Experience Will Help CMs Help Patients Q: A: MAUREEN BOSHIER, RN, MSN, MBA, LP.D., FACHE FELIZITAS DEVINE, RN, MS, MBA, CCM W What will be the role of the case manager in accountable care organizations under the new federal health care law? org g The 2010 Patient Protection and Affordable Care Act T (PPACA) includes demonstration pilots for accountable care organizations (ACO) in a renewed and serious effort to reduce waste and to push Medicare costs down while improving quality and efficiency. The law has set some ACOs as pilots in an effort to help reduce health care costs. Keep in mind that ACOs also are organizations of health care providers accountable for the quality, cost, and overall care of Medicare beneficiaries enrolled in the traditional fee-for-service program assigned to them – that is the quality aspect. Many types of organizations can become an ACO. Examples of some are as follows: • Physician group practices; • Partnerships between physician groups and hospitals; or • Hospitals that employ physicians. the Big Three components of health care delivery: quality, cost, and access. Typically, any two, but not all three, are concurrently achievable. Yet the demographics of the aging Boomers, the anticipated increase in the number of people with insurance, and the decline in the availability of primary care providers converge to resurrect thinking about how to get to the job done with the Big Three in play. Although regulations, reimbursement paths, and other pieces of an ACO delivery system currently lack specificity, it is clear enough to case managers and others involved in health care delivery that the patient-centered medical home, population health management, and smooth coordination of care and patient information will be requisite. The practice of professional case management is a bridge between fragmented silos of care and the reach for better coordination and continuity of care that are the core of an ACO model. To be successful, the structure of an ACO will need to be designed and coordinated locally. SOME STATISTICS Today, 54 percent of ACOs include a hospital and 30 percent also include a pharmacist. The majority of ACOs will initially be administered by physicians, with 39 percent of ACOs having fewer than 100 physicians. Current ACOs are responsible for 10,000 or more people. Beneficiaries, though assigned to an ACO, may still seek and receive services from providers that are not part of the ACO. January is the expected launch date. Providers and facilities delivering these health care services will be offered financial incentives if they provide quality care to Medicare beneficiaries while keeping costs down. Shared savings is built into 40 percent of current ACOs’ reimbursement models. Short-term savings could be realized in decreased emergency department visits and inpatient admissions. Longer-term savings could be in the form of overall fewer health dollars spent on someone with a well managed chronic condition. CASE MANAGERS ARE READY NOW No professional member of the care continuum is better prepared to work in a coordinated care network than the professional case manager. The primary role of the case manager has always been to ensure that cost-effective care is delivered in a timely manner. In order for an ACO to be effective, the case manager will need to exceed expectations in patient engagement. Additional efforts will need to be made in establishing patient contact, and once patients are reached, educating those patients about the benefits of being involved in their health care must be delivered efficiently and effectively. Once engaged, keeping patients motivated to participate will be vital. Coordinating care has always been a core competency for a case manager – management is a strong foundation and necessary component of efficient coordination. The U.S. health care system has become more complicated than ever, with many patients seeing multiple providers in different venues, and each patient with his or her own health record. Ensuring that patients move through these different arenas with no interruption in care will be critically important to an ACO’s success. Quickly identifying gaps in care and taking prompt action will ensure that continuity of care is Issue 2 • 2011 CMSA TODAY 37 THE GOAL: COVERING ALL CONCERNS To date, there are few examples of models or organizations that boast a properly and equitably balanced combination of

Table of Contents for the Digital Edition of CMSA Today - Issue 2, 2011

CMSA Today - Issue 2, 2011
Table of Contents
Outgoing President’s Letter
Incoming President’s Letter
How Care Coordination Affects You
Demonstrating Case Management’s Value to Hospitals’ Bottom Line
Making the Case for Evidence-Based Case Management Practice and Programs
Association News
Ask the Expert
Facility Profile
View From Capitol Hill
Case Management and the Law
Ethics Casebook
Mentoring Matters
Index of Advertisers

CMSA Today - Issue 2, 2011