Welcome to Week 8, Chapters 7, 22 and 27. The time has never been better for a new breed of case managers—the direct-to-consumer, c
ommunity-based case manager. The convergence of consumer-driven healthcare, wherein consumers take a more active role in
decisions regarding their healthcare, and the overburdened healthcare system has made the need for accessible, dedicated patient advocates
more critical than ever. The rising costs of healthcare are further driving the need for professionals who are more directly involved and
accountable to patients, and patients alone. Although community-based case managers can focus interventions on patients and their families,
they need to continue to foster positive, cooperative relationships with their patients' physicians, healthcare providers, and payer
groups. A direct-to-consumer case manager needs to able to envision themselves as their own boss and an entrepreneur providing case
management services to members of the local community. Necessary traits include self-discipline, self-motivation, confidence, and
organizational skills to manage my own business. Case managers existed as far back as the early 1900s, when they served as care
coordinators for patients requiring integrated, multidisciplinary healthcare services. At that time, they were employed by public health service
providers. Soon, they entered another venue wherein their services were used in cases involving certain types of patients (i.e., lower
income patients, those with mental illness, older adults). By the mid-1970s, the first generation of case management developed in the context of
rehabilitation management. From there, case managers gained the attention of certain insurance companies that saw rehabilitation
case management as a means to manage their cases more effectively and generate a new revenue stream. The advent of AIDS in the 1980s
ushered in the next phase of case management. This disease, with its high cost of treatment and multidisciplinary requirements, was viewed as
particularly well suited for case management and the associated risk management designed to contain costs. All of the blame, however, cannot
be placed on the shoulders of the carriers, the providers, and "the system." Case managers must also assume some responsibility because
they did little to articulate and highlight their intrinsic value. Now, within the parameters of the 21st-century healthcare system and its dire need
for change, there is a tremendous opportunity for case managers to be that agent of change and make a real difference.
To serve effectively as change agents, direct-to-consumer, community-based case managers must do the following:
Advocate for their role in the community. Embrace an entrepreneurial, can-do attitude. Gain greater financial awareness about the costs
associated with health care. Assume the role of "go-to" person with patients and their family members.
Think globally while acting locally and staying connected to providers, employers, trusted advisors, healthcare advocacy groups, and
nonprofit organizations As in other entrepreneurial endeavors, there are advantages and disadvantages in going it alone,
and one should evaluate them carefully before hanging out a shingle. Being given the opportunity for success does not automatically
guarantee it, nor does being a truly excellent case manager guarantee profits.
The benefits are numerous. As the statistics bear out, case management has been and will continue to be one of the most effective tools in
the growing array of cost-containment and quality assurance tools in the marketplace today. There are drawbacks as well. When case
managers leave an organization, they usually miss the camaraderie with colleagues and friends to have lunch with, discuss goals and
dreams with, commiserate with, and have fun with. In addition to those who shared a profession, case managers could draw on other
departments and associated personnel to help them learn about and develop an area of expertise.
Whether you are working to revitalize a case management department or start an independent business, the creation of a
business plan should be your first move. The following is a list of important issues to address: Type of company
Location Size Financial resources S
hort- and long-term goals Before becoming an independent case manager, you also need to access your personal skill set,
know your strengths and weaknesses, envision your type of business, define your nature and personality, decide what role you want to play.
Every case management company and independent practitioner must consider others in the community who are in the same field.
Competition is good. It keeps case managers on their toes and helps them stretch toward excellence.
Because the business sector pays the largest share of healthcare costs, a closer alliance between case managers and this concerned
group is essential. The object should be not only to improve individual working relationships, but also to increase the public's awareness of case
management in general. To keep their voices in the forefront regarding healthcare issues, case managers need to submit articles to business
publications, join community and business group coalitions to address healthcare concerns, and meet with business and healthcare leaders
to tell them about the advantages of case management programs. Case management is much like other
businesses and has many of the same requirements. It is necessary to be aware of personal and business limitations and to
contract or arrange for assistance in dealing with critical day-to-day management issues. Because even successful businesses
experience peaks and valleys, having a plan to generate new clients is always important. When starting a business, it is very important to
identify and accept the kinds of cases that present the most potential for success, both in terms of medical outcome and cost savings.
Although we all welcome a challenge and want to demonstrate that we can do what others cannot, we do not want to attempt the impossible. This
does not mean taking only easy cases; the easy ones do not usually require case management. There are, however, many cases between the two
extremes. Expressing appreciation for past and current business is important in maintaining ongoing
associations and generating new referrals. Sharing information about conferences or articles that might be of interest is one way to
expand relationships. Everyone defines success differently. For those who choose the entrepreneurial path, the ultimate goal may be
the fulfillment of the work–life balance. Others may choose to grow and nurture something that reflects their passion. Our goals are often less
about monetary issues, than quality of life Independent hospitals are becoming less the
norm and more the exception. This is a function of both the incentives offered by the ACA and the reduced use of inpatient care. The trend of
healthcare provider consolidation is not expected to end anytime soon. For case managers, consolidation among
providers can have a profound effect. Case management departments, which have many different names, will also be consolidated,
thereby forcing some case managers out of their current positions. As decision-making power becomes more centralized and controlled by
fewer entities, it becomes even more important for case management department supervisors and staff to strive for higher visibility and
demonstrate the value of case management. As new models of care continue to grow and evolve, case managers will face new challenges,
including those that test their professional ethics. We now have a wide range of healthcare models, from consumer-driven healthcare insurance
plans, such as high-deductible plans, to new care delivery models, such as PCMHs and ACOs. The ACA has played a significant role in this
emphasis on accountability and the transition to a value-based healthcare delivery system. In April 2013, an event was held to discuss how
America's healthcare delivery system would transition from its former volume-based model to that of a value-based model. The report had
some clear conclusions: the ACO's incentive-based model outperforms the Medicare fee-for-service model in clinical quality and patient
experience; improving and standardizing data for quality management is essential; and more successfully transitioning to a value-based
system will require a continued focus on improving patient health and well-being. The ethical challenges for case managers
(Chapter 12) raised by the value-based model and its core goals come in several areas, most of which stem from the changes imposed by the
ACA. CCMs must adhere to the rules of conduct they agree to when they earn their CCM designation. The PCMH setting also introduces
new challenges for case managers related to medical errors and the heightened focus on quality performance and metrics within value-
based health care. With a greater reliance on technology, case managers may find a high incidence of medical errors, a large percentage
of which can be traced back to technology. The new quality reporting provisions under the ACA, combined with the transition to value-based
health care and the professional standards governing case managers, require medical errors to be reported.
The increasing shortage of primary care physicians continues to characterize health care in America. Currently, more than 58 million
Americans live in regions officially referred to as primary Health Professional Shortage Areas (HPSAs)—areas in which the number of primary
care physicians compared to an area's population is below federal standards. The growing shortage of primary care physicians
can be attributed to the expanded health insurance coverage ushered in by the ACA, along with the increase in the number of baby boomers
who are aging. The sheer size of the baby boomer generation is expected to be one of the most significant forces affecting health care in
America. Their longer life expectancies, compared to their parents, coupled with high rates of certain chronic medical conditions, such
hypertension, high cholesterol, diabetes, and obesity, will contribute to rising healthcare costs and the need for more primary care services.
As a result of the urging of the NGA and the IOM, as well as the NCSBN APRN Advisory Committee and the APRN Consensus Work Group's
issuance of its APRN Consensus Model in 2008, which was endorsed by more than 40 APRN stakeholder organizations, a goal was set to
better align the licensing, accreditation, certification, and educational requirements for an evolving primary care role for nurse practitioners.
Currently, nurse practitioners have full primary care practice authority in 20 states and the District of Colombia. Further, it is estimated that
almost 90 percent of all nurse practitioners are educated, trained, and ready to provide primary care services.
Polypharmacy can be simply defined as taking more than five medications. It can also include inappropriate medication use, such as the use of
prescription or nonprescription medications that have no legitimate indication, the use of multiple medications to treat the same condition, the
simultaneous use of interacting medications, an inappropriate medication or dosage, and the use of a medication to counteract the side effects of
another medication. The aging process brings a myriad of medical conditions and chronic diseases, many requiring
complex therapeutic regimens. Problems associated with multiple medication use include noncompliance with drug therapy, over- or
underdosage, therapeutic duplication, off-label use, contraindicated use of medications together, drug–drug interactions. In addition, some
medications can simulate diseases. Polypharmacy often results because a patient is under the care of multiple physicians.
In 2012, CBS News online published an article on polypharmacy that outlined the issues with taking multiple drugs. The article notes that the
percentage of people aged 60 years or older who take five or more medications has jumped from 22 to 37 percent.
As defined by The Joint Commission, medication reconciliation is "the process of comparing a patient's medication orders to all of the
medications that the patient has been taking." The medication reconciliation process consists of five steps:
1.Develop a list of current medications. 2.Develop a list of medications to be prescribed. 3.Compare the medications on the two lists.
4.Make clinical decisions based on the comparison. 5.Communicate the new list to appropriate
caregivers and to the patient. There are some ways for case managers to avoid negative interactions when clients have a polypharmacy
situation: Have them keep a list of all their medications, including vitamins and over-the-counter items.
Go online. There are many websites where you can check whether there are potential problems in a medication regimen.
Appoint a lead physician. Ask the pharmacist.
The opposite problem is medication nonadherence. The National Council on Patient Information and Education states that 40% of
seniors are unable to read prescription labels and 67% are unable to understand information given to them.
Thirty-two million Americans are taking three or more medications daily.13 According to the
Council on Patient Information and Education, nearly half of patients do not adhere consistently. Common behaviors, such as forgetfulness and
procrastination, may result in the wasteful spending of $163 billion annually. The 10 most prescribed drugs in the United
States are not the drugs on which we spend the most. Seventy-eight percent of the nearly 4 billion U.S. prescriptions written in 2010 were for
generic drugs. In 2010, the most prescribed drugs were: hydrocodone, generic Zocor, lisinopril, generic Synthroid, generic Norvasc,
generic Prilosec, and hydrochlorothiazide. The drugs on which we spend the most money are those that are still new enough to be
protected against generic competition. For many years, the world of pharmaceuticals has been very dynamic, with new drugs being
developed at unprecedented rates and clinical trials following close behind. Over the past several years, we have witnessed deaths
attributed to side effects from FDA-approved pharmaceuticals that were used as prescribed and according to the manufacturer's protocol.
Case managers have the opportunity to assume a greater role in advocating and caring for their patients by becoming more proactive and
informed regarding prescription medications, their side effects, and the potential for overdoses associated with certain medications, in particular
pain medicines. Especially when patients have comorbid conditions requiring interventions and prescriptions to be made by several physicians
from a variety of settings. Case managers must be the voice of reason, advising and counseling to ensure that patients
are fully informed about the potential risks and complications, as well as the benefits. Case managers, unfortunately, are occasionally in the
position of knowing that a medication is being used off label, but because we see ourselves as patient advocates, we are reluctant to report the
matter. The conflicting loyalties described here are vexing and are the reason why organizations need to establish ethical guidelines and
committees to address such matters. The role of case manager is a demanding and ever-expanding one. Keeping abreast of the
many resources, including those of the pharmaceutical industry, is getting to be more complicated but is an extremely important
component of the work that we do. The valuable contributions to healthcare of the pharmaceutical companies cannot be underestimated, and I
encourage organizations and individuals to take advantage of the many educational opportunities they make available to professionals and
patients.
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