Care Management Training is Key to Effectively Addressing Diverse Needs
One could argue that health plans use case managers in much the way a financial advisor manages a client’s portfolio. By evaluating the client’s needs and determining how to provide care efficiently using the resources at hand, care managers are able to keep costs down and ensure clients get the best care possible.
On the surface, it is easy to think the job description for a case manager is simple and straightforward, but the role has many moving parts, requiring a skill set that ranges from expert communicator, to adept multi-tasker, to team player and coach.
Case Managers Play Multi-Faceted Role
Care managers wear many different hats and function in a multi-faceted role that grows in complexity with challenging client cases. Health plan case managers are mediators, educators, negotiators, moderators, and experts. From day-to-day, the case manager must work with clients, providers, and payers, each with a distinct view of what constitutes appropriate care.
The client is seeking expert care to manage their complex condition; the health plan is focused on the same goal, knowing better disease control will improve the client’s health and reduce unnecessary hospitalizations, ultimately saving money. Case managers also spend their days talking to employers, adjusters, and attorneys as they are the go-between in each step of the process.
The difference in managed care between 1983 and today is staggering. In the past, case managers were not used, except for private firms and state agencies. Today the situation has changed completely as companies, physicians, and clients recognize the difference in healthcare available to those whose cases are managed and coordinated well from one location.
The case manager is not managing medical care as a physician, but rather seeking to apply healthcare benefits wisely for the client.
Experts in Managing Chronic Illness
A health plan case manager integrates information from hospital case managers, home health companies, physicians’ offices, and other healthcare providers. The goal is to ensure the client gets medically necessary quality care as efficiently and economically as possible. This is especially important when clients suffer from long-term chronic disease.
Chronic illnesses last for six months or longer and include health problems such as arthritis, cancer, asthma, HIV, diabetes, heart disease and obesity. Nearly 80% of seniors have at least one chronic health condition and 68% have two or more. The U.S. Centers for Disease Control and Prevention finds 60% of all adults have a chronic disease and 40% have two or more. Of the top 10 leading causes of death in the U.S., seven are chronic, long-term illnesses.
It should come as no surprise that health plan case managers are important team players in administering and reducing healthcare costs.
Care Managers Require Special Training
In some companies, the case manager’s scope of work is limited to those with specific chronic diseases. In others, case managers are expected to become expert at coordinating the care of multiple conditions. The need to effectively manage care for clients with complex needs or those from diverse populations requires high-quality training in topics like critical thinking, care planning, motivational interviewing, and more.
Relationship building is another important case management strategy that benefits from effective training. Clients may believe a case manager’s singular goal is to reduce the cost to the health plan by any means possible, including by negatively impacting the client’s healthcare and outcomes.
As a case manager it is your responsibility to gain the trust of your client as this is the only logical and realistic way of improving client outcomes and thus reducing healthcare costs in the long run.
Henderson, M.G., Souder, B.A., Bergman, A., Collard, A.F. Private Sector Initiatives in Case Management. (1988) Medicare & Medicaid Research Review 1988(Supplement):89-95
Gray B.H., Field M.J. Controlling Costs and Changing Patient Care? The Role of Utilization Management. (1989) National Academies Press. High-Cost Case Management Institute of Medicine
Office of Science Policy, Planning, and Communications. Chronic Illness and Mental Health. National Institute of Mental Health, National Library of Medicine
Legg, T.J. (February 23, 2017) The Top 10 Leading Causes of Death in the United States. Medical News Today
About Chronic Disease (November 19, 2018) U.S. Centers for Disease Control and Prevention