2. Objectives
1. Define Case Management within the context of Clinical
Research
2. Explain the role of Case Management process through a
case study scenario
3. Demonstrate the impact of strategic collaborative care
coordination
4. Describe care coordination processes that optimize the
implementation of seamless healthcare services
3. Case Management
Definition: Case Management is a
collaborative process of
assessment, planning, facilitation, care coordination,
evaluation, and
advocacy for options and services
to meet an individual’s and family’s comprehensive health
needs
through communication and available resources
to promote quality cost-effective outcomes.“ (Case
Management Society of America)
4. Case Management Components
Facilitating the seamless delivery of health care services in a patient centric model of care designed
to minimize fragmentation
Single point of contact – Case Manager
Case screening – Risk assignment
Assessment – Face to face or telephonic
Plan of Care – Patient-centric/multidisciplinary
Collaboration – Case Management is a team sport!
Implementation – Care coordination
Evaluation – How did the plan work?
Multidisciplinary Team Meetings Facilitated by the
Case Manager – Herding cats
Implementation – Activation of recommended team interventions
Evaluation – Ongoing Care Plan Updates
5. Case Management Process
Deliberate organization of patient care activities
Inclusion of PCP, Specialist, Patient, Family, Clinical Research Coordinator and
other clinicians on the Multidisciplinary Team
Shared healthcare information among all healthcare team participants
Shared goals to achieve safer, more appropriate, more effective care as well as
accurate study outcomes
Prioritizing the patient’s needs and preferences
Committed Collaborative Multidisciplinary Team Participants - show up to play
Optimize awareness of the patient’s preferences, goals and priorities
Embed patient goals into the collaborative plan of care
Identify and prioritize strategic interventions
Communicate planned and proposed patient interventions, outcomes, and
barriers
7. Case Management Standard Changes
and Healthcare Reform
As the healthcare industry changes - Case management takes the lead
The standards for case management address important foundational knowledge and skills of the case
manager within a spectrum of case management practice settings and specialties
1995 – the first standards for CM identified gaps in the health care continuum
2010 – standards updates identified the impact of fragmented
health care and included the following revisions:
Minimization of health care fragmentation
Use of evidence based guidelines in practice
Navigation of transitions of care
Incorporate adherence guidelines and other standardized practice
tools
Expand the interdisciplinary team in planning care for individuals
Improving patient safety
8. Lucy’s Story
Lucy is a 66 years old
Medical History
Type II Diabetes
Hypertension
Chronic Anxiety and Depression
Obesity – BMI 32.6
Arthritis
Cataracts
Dyslypidemia
Demographics
Widowed
Lives alone
Daughter lives nearby
Does not drive
Medications: Norvasc 10 mg, Paxil 30 mg, Wellbutrin 300 mg, Metformin 1000 mg BID, Atorvastatin 20 mg,
Advil, Calcium, and Daily Vitamin
PCP, Endocrinologist, and Psychologist
9. Lucy’s Story
Elevated blood pressure during a follow up PCP blood pressure check
appointment (182/112)
The PCP prescribes Lisinopril 20 mg
Lucy fills it at the Rite Aid near her PCP office that same day but doesn’t add to her pill
box
Lucy sees her Endocrinologist 2 days later during a scheduled appointment
Again, her blood pressure is elevated (180/112) and some pedal edema
This concerns the specialist who was readying Lucy for participation in a diabetic
medication clinical trial
Lucy is anxious to participate in a diabetic medication study b/c of the weight loss side
effect
She cannot begin until her BP is under control
The specialist prescribes Zesturetic 10/12.5
Lucy’s friend picks up the Rx for her at the CVS pharmacy on the way home
The Endocrinologist schedules a follow up appointment in 2 weeks to assess her
stabilization of her BP and readiness to participate in the clinical research
10. Lucy’s Story
She is excited to begin in this 6 month study because
she will get $400.00 AND
the study medication has been proven to contribute to weight loss
She plans to start her new medications immediately
She only has to take the medication once a week
Lucy adds her newly prescribed medications to her pill box that evening
She takes her medications as prescribed the following morning
At 11 AM after standing up from her recliner Lucy feels dizzy and falls
Lucy fractures her hip
Ah Oh! What went wrong?
11. Lucy fell into the BIG BLACK Hole of
Care Fragmentation
.
Healthcare Silos
Communication
Collaboration
Untoward side effects
Preventable admissions
Preventable complications
Preventable emergency
department visits
Preventable readmissions
Complications
Increased care costs
Medication Errors
Patient education gaps
12. Care coordination
The Missing Links
Lack of a single point of contact
Un-effective model of care
Failure to consider patient priority
Missing team collaboration and communication
No patient engagement
No patient education
Duplication of services
Team Members out of the
loop
13. Single Point of Contact
Minimizes healthcare fragmentation and navigation
confusion
Facilitates Multidisciplinary Team collaboration
Coordinates discharge planning
Coordinates transitions of care
Establishes safe and effective outpatient care services
Identifies home safety issues
Breaks down barriers to optimal care
Connects the communication dots
Prevents duplication of services
Ensures compliance with clinical guidelines
Engages the patient in healthcare goals and decisions
Incorporates the Member’s priorities into the health care plan design
14. Patient Centered Model of Care
Promotes active involvement of patients and their families in
decision-making about individual options for treatment.
"Providing (coordinating) care that is respectful of and responsive to
individual patient preferences, needs, and values, and ensuring that
patient values guide all clinical decisions.
“(The IOM definition of Patient Centered Care - Institute of Medicine)
Enables active patient engagement at every level of care design and
implementation.
15.
16. Lucy’s Care Coordination Gaps
Case Analysis: What if Lucy had a Case Manager?
She sees her PCP and an Endocrinologist regularly – Missing Link
The PCP prescribes Lisinopril 10 mg– Missing Link
Lucy sees her Endocrinologist 2 days later during a scheduled appointment –
Missing Link
The specialist prescribes Zesturetic 10/12.5 for Lucy
Her friend fills the RX at a CVS pharmacy near her home – Missing Link
She is excited to begin this 6 month study because she will get $400.00 AND
the study medication has been proven to contribute to weight loss – Missing
Link
Lucy adds her new medications to her pill box the evening after her specialist
appointment – Missing Link
She takes all her medications as prescribed the following morning – Missing
Link
17. Case Management Impact in Clinical
Research
Deliberate organization of patient care activities
Inclusion of Clinical Research Coordinator on the Multidisciplinary Team
Shared healthcare information with all healthcare team participants.
Team understanding and agreement on shared goals to achieve safer, more appropriate,
and more effective care
Prioritizing the patient’s needs and preferences
The healthcare team seeks to discover medication to lower A1C
How does Lucy’s weight loss goal fit into the plan of care?
Committed Collaborative Multidisciplinary Teams – Sharing the same sheet of music
Optimize awareness of the patient’s preferences, goals and priorities
Create a collaborative and focused plan of care
Identify and prioritize strategic interventions
Coordinate planned and proposed patient interventions
Agreement related to breaking down barriers
18. Collaboration
Communicates with all Team Members – Multidisciplinary Team Meetings and Individually
PCP
Specialist
Clinical Research Coordinator
Case Manager
Patient
Daughter
Others selected by the Patient
Prevents duplication so lab tests
Prevents duplication of BP medications
Prevents dizziness, falls, fracture and concussion due to medication complications
Ensures all treatment team members have the same information
Ensures that the daughter is educated regarding her mother’s conditions and treatments
Collaborates with the Clinical Research Coordinator regarding Member readiness for study; ensures
Coordinator has all appropriate healthcare information
Ensures that he Endocrinologist had complete healthcare information relevant to Lucy’s status and
her PCPs concerns
19. Lucy on Care Coordination
The Case Manager (Payer)
Completed Case Manager comprehensive assessment
Calculation of healthcare risk
Enrollment in disease specific programs
Validation of patient demographics
Care Plan shared with the PCP and patient
Inclusion of Lucy’s healthcare priorities (weight loss) in the plan of care
PCP and Specialist input into the plan of care
Communication of healthcare information, clinical study participation and scheduled
appointments
Inclusion of Lucy’s healthcare priorities (weight loss)
Seamless circle of shared healthcare information
Considers impact of Lucy’s depression
Shared focus on closure of key gaps in care
Lucy’s A1C is high – is she testing? Does she understand her diet? What role does exercise plan? When did
she last have blood tests? Were results of all testing shared among the healthcare team?
20. References
http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html
www.pcpcc.net Colorado Systems of Care/Patient Centered Medical Home Initiative: Colorado
Primary Care – Specialty Care Compact
www.pcmh.ahrq.gov
www.caaretransitions.org The Care Transitions Program. Eric Coleman, MD, MPH by The MacColl
Institute for Healthcare Innovation
Affordable Care Act
Medicare-Medicaid Regulations/care coordination standards
The Clinical Trials Office of Henry Ford
www.wmsa.org
www.ncqa.org/NCQA Care Coordination Standards
Medicare-Medicaid Program Dual Eligible Regulations
https://en.wikipedia.org/wiki/Case_management_(USA_health_system)
Notes de l'éditeur
If holistic care coordination is the goal then all job titles are equal … But
Verify who you are talking to
Verify what their job is
How you can work together tor optimal patient outcomes
Utilization Review is not Case Management
The many names of Case Managers
Care Managers
Clinical Coordinators
Patient Advocates
Case Worker
Care Collaborator
Care Reviewer
Zesturetic 10/12.5 = Lisinopril and Hydrochlorthiazie combo
All add up to poor quality and high costs $$$
New drugs, therapies, treatments, models, regulations, quality metrics, HEDIS, Medicaid Expansion …
Past healthcare leaps created specialty niches for Case Managers (no longer one size fits all)
High Risk Pregnancy
Behavioral Health
Pediatrics
Transplants
Transplants by Organ
Worker’s Compensation
Sickle Cell
Clinical Research
Genetic Medicine
Disease Management
Clinical Research and/or Genetic Case Management?