Pursuing the Promise of Care Coordination With Qualified, Credentialed Professionals

Passage of the Patient Protection and Affordable Care Act has put the spotlight on a key component of service delivery: care coordination. From the aging population to the prospect of millions of previously uninsured Americans, including many with pre-existing conditions, now having access to healthcare coverage, there is an urgent and growing need to facilitate and streamline what can often be a fragmented and inefficient process.

With care coordination seen as essential to improving quality and outcomes in healthcare—particularly for vulnerable populations such as the elderly, those with multiple chronic conditions, and people with disabilities—it raises a significant question: who is providing this service? Care coordination, which also encompasses case management and care management, involves direct clinical interventions delivered to individuals. Therefore, in order for care coordination to live up to its promise of improving the efficiency and efficacy of healthcare, consumers deserve to receive these servicers from competent and credentialed professionals.

First, let us consider the potential for care coordination to improve the delivery of care and treatment and to preserve scarce and costly resources. The National Quality Forum (NQF) has stated that care coordination “helps ensure a patient’s needs and preferences for care are understood, and that those needs and preferences are shared between providers, patients, and families as a patient moves from one healthcare setting to another.” (NQF, 2010)  Care coordination is considered especially important for people with chronic or complex conditions who receive care in multiple settings from numerous providers. The NQF has also stated that care coordination “maximizes the value of services delivered to patients by facilitating beneficial, efficient, safe, and high-quality patient experiences and improved healthcare outcomes.” (NQF, Definition and Framework)

Care coordination is widely seen as having the potential to address the systemic problems in healthcare, as highlighted by the Institute of Medicine in its groundbreaking 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century.” Problems identified in the report include a lack of coordination within the delivery system, fragmentation that slows care and undermines accountability, poor communication and use of information technology, and failure of health professionals to work together to ensure that care is appropriate, timely, and safe. (IOM, 2001)

Further elevating the focus on care coordination, in its May 2010 draft report, “A Strategic Framework 2010-2015: Optimum Health & Quality of Life for Individuals with Multiple Chronic Conditions,” the U.S. Department of Health and Human Services (HHS) Interagency Workgroup on Multiple Chronic Condition set forth as one objective to “improve care coordination through introduction of proven and potentially effective patient care management models.” It further noted that several new models—including patient-centered medical home, community health teams, and accountable care organizations—have emerged in recent years that emphasize “interdisciplinary care, and provider communication and cooperation.” (HHS, May 2010)

In addition, the HHS Office on Disability awarded more than $6 million to establish a Center of Excellence in Research on Disability Services, Care Coordination and Integration.  As HHS has stated, “Evidence shows that well-designed and implemented care coordination can help persons with disabilities live independently longer, and with added years of quality life. Care coordination/care management may be even more vital for certain populations, such as individuals with multiple chronic conditions and those with higher levels of disability.”  (HHS.gov)

Given the high expectations for care coordination, it is important to ensure that patients needing these services receive them from competent professionals with the requisite knowledge, skills, and expertise. Case managers are uniquely positioned to serve in a care coordination role because of their competencies and qualifications. The Commission for Case Manager Certification (CCMC), the first and largest nationally accredited organization that certifies  multi- disciplinary clinically trained case managers, describes case management as, “…A collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes.”

As an advanced practice within health and human services, case management brings together diverse professions such as nursing, social work, rehabilitation counseling, occupational therapy, and others. The CCMC states, “…the case manager links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. This approach achieves optimum value and desirable outcomes for all—the clients, their support systems, the providers, and the payers.” (CCMC, Definition)

Case managers demonstrate their competency to provide this service through certification, such as attainment of the Certified Case Manager (CCM) credential, which attests to their education, experience, through an evidenced based examination and mandatory continuing education. Such competency is critical to the case management process, particularly the ability to conduct an independent assessment, which is the basis of the care plan. As stated in the CCMC’s Certification Principles, certified case managers are obliged to:

• Place the public interest above their own at all times.
• Respect the rights and inherent dignity of all their clients.
• Act with integrity in dealing with other professionals and facilitate their clients' achieving maximum benefits.
• Keep their competency at a level that ensures their clients will receive the benefit of services that are appropriate and consistent for the client's conditions and circumstances. (CCMC, Certification Principles)

These principles speak to the value of the case manager, and in particular those who are certified, to provide care coordination and to facilitate communication among all parties, especially patients and their families or other support systems.

Further, the competencies associated with the advanced practice of case management, as demonstrated through a valid and thorough credentialing process such as the CCM certification, increase the likelihood that case managers in care coordination roles can effectively perform this service. Certified case managers respect, appreciate, and assimilate the diverse perspectives of a multidisciplinary team of professionals and patients/clients to achieve person-centered, quality cost effective care and outcomes. Certified case managers have demonstrated competencies that include creating synergy within diverse teams of health and human services professionals with a focus on the best interests of patients/clients as they pursue optimal outcomes.

Therefore, case managers are essential to the oversight and coordination of care across settings and providers. This is particularly important when addressing transitions of care, in which a patient/client is moved from one setting to another, such as primary care to a specialty physician, within the hospital, or from hospital to home, assisted living, or skilled nursing facility. The National Transitions of Care Coalition and others have identified transitions of care as an area of concern that can only be addressed by “breaking down silos and barriers between different health care settings and working collaboratively for the good of the patient.”  (NTOCC.org) Once again, such skills speak to the expertise of the certified case manager who coordinates and facilitates care across the health and human services spectrum to encourage the sharing of information and documentation for the good of the patient/client.

It should also be emphasized that case management is a quality improvement activity, whether the case management services are delivered through a health plan, in a hospital, or in any other setting. In order for case management to continue to be a quality activity, it must be performed by competent, qualified, and credentialed professionals. In other words, who is providing the service is more important than where the case manager is employed. Whatever the setting, it is inappropriate to have case management or care coordination interventions performed by administrative personnel who are neither qualified nor competent to deliver them. The potential risks to the public of having case management services provided by those without the appropriate education, knowledge, and skills continues to be a source of debate and concern amid the professional community.  Issues such as professional shortages, increasing demand, and potential payment by the Centers for Medicare and Medicaid for case management services have brought to the forefront the importance of who provides care coordination services. Because almost anyone can call himself a case manager, a valid and rigorous credentialing processing such as certification is one of the few ways to know that an individual is qualified for this role.

Also impacting case management quality is the Medical Loss Ratio (MLR) in the healthcare reform legislation. Starting in 2011 insurers must meet a minimum MLR (the percentage of premium dollars spent on providing healthcare) of 80% for individuals and group health and 85% for the large group segment. The remaining percentage is used to pay administrative expenses such as salaries, advertising, agent commissions, overhead, and profits.

In its letter to the National Association of Insurance Commissioners (NAIC) regarding the MLR, the CCMC urged that care coordination/case management be considered a medical expense or quality improvement expense, as opposed to an administrative activity. Such classification acknowledges the direct impact of care coordination/case management on the patient/client, and would also help ensure that these services continue to be provided by licensed, credentialed, and qualified professionals.  If these services are classified as administrative under MLR, then insurers, one of the largest employers of case managers, may have to lower costs. This could lead to having administrative personnel provide these services, as well as reducing the number of people providing the service. This potential scenario will severely undermine case management effectiveness and compromise outcomes and safety for patients, particularly vulnerable populations such as the frail elderly and those with multiple co-morbidities.  Therefore, regardless of how care coordination/case management is ultimately classified under MLR by the NAIC/HHS, it is essential that qualified and competent professionals provide these services.

Care coordination deserves the attention it is receiving as a solution to an entrenched problem: the need to improve quality, efficiency, and efficacy of care in the United States. As the discussion continues, we must keep in mind that, ultimately, care coordination is about the patients /clients. In order to provide the best quality and most cost-efficient care and treatment, healthcare professionals from a variety of disciplines must engage in open dialogue in a mutually respectful environment. Within this dynamic, it is essential to promote cooperation and collaboration through the expertise of a case manager. Certification attests to the suitability of a case manager for this role because he/she possesses the requisite knowledge, skills, and expertise, and is held to high standards of ethics and accountability in practice.

If care coordination is to live up to its potential, it must be the domain of professionals who are qualified to perform this service. Otherwise, care coordination will fall short of its potential, and many of its patient-centered goals will become nothing more than broken promises in a fragmented healthcare system.

REFERENCES:

National Quality Forum, Endorsing Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination, 2010,

http://www.qualityforum.org/projects/care_coordination.aspx?section=Publicand    MemberComment2009-10-26#t=1&s=&p= Accessed July 23, 2010

National Quality Forum, NQF-Endorsed Definition and Framework for Measuring Care     Coordination, May 2006, Endorsed 2010,

http://www.qualityforum.org/projects/care_coordination.aspx?section=Publicand    MemberComment2009-10-26#t=1&s=&p= Accessed July 23, 2010

Institute of Medicine, Committee on Quality of Health Care in America. Crossing the

Quality Chasm. Washington, D.C., National Academy Press. 2001.

U.S. Department of Health & Human Services, Interagency Workgroup on Multiple Chronic

Conditions. A Strategic Framework 2010-2015: Optimum Health & Quality of Life for Individuals with Multiple Chronic Conditions. May 2010 (draft)

http://www.hhs.gov/ophs/initiatives/mcc/federal-register051410.pdf

HHS.gov, “Center of Excellence in Research on Disability Services Care Coordination and Integration,

U.S. Department of Health & Human Services. http://www.hhs.gov/od/cerds.html
    Accessed July 23, 2010

Commission for Case Manager Certification, “Definition of Case Management,”

http://www.ccmcertification.org/secondary.php?section=Case_Management
    Accessed July 23, 2010

Commission for Case Manager Certification, “Certification Principles,”
http://www.ccmcertification.org/secondary.php?section=Certification&content=CertificationPrinciples Accessed July 23, 2010

National Transitions of Care Coalition, http://www.ntocc.org/ Accessed July 23, 2010

About The Authors

Annette C. Watson, RN-BC, CCM, MBA, is Chair of the Commission for Case Manager Certification (CCMC) (www.ccmcertification.org). The CCMC is the first and largest nationally accredited organization that certifies case managers. She is also Managing Director of Global Emerging Business for CARF International, a leading accreditor of health and human services programs worldwide.

Ellen Fink-Samnick, LCSW, CCM, CRC, is a Commissioner of CCMC and past Chair of the Commission’s Ethics and Professional Conduct Committee. She is also president of EFS Supervision Strategies, LLC in Burke, Va., and has 27 years of experience developing innovative case management models for health and mental health care. She also serves as Adjunct Faculty for George Mason University’s College of Health and Human Services.