September 4, 2024: The Challenge of Complex Care Management Part A
Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care – Part 19
One of the main objectives of primary care and within value-based payment models is to improve patient outcomes and reduce the cost of care. The top 8-10% of the population consumes about 80% of the healthcare dollar in the United States. The highest risk patients on every primary care clinician’s panel are those with complex medical, psychological and social needs.
In the current fee-for-service paradigm, many health systems, insurers and ACO’s have moved nursing resources from direct clinical nursing to care management roles to try to assist this highly vulnerable population. However, care (or case) management has often grown out of inpatient nursing departments, moving to transitional care management (to prevent readmissions) and now are trying to perform in outpatient settings with very mixed levels of success.
We have observed and scrutinized a number of care management services, and we see several common themes that we feel need to be addressed if we are to truly have an impact on improving patient outcomes AND retain skilled, caring nurses to perform this vital service. We will dissect these in a series of blogs to dig deeper into the issues that many if not most care management services face.
- Care management nursing often faces a conflicting set of requirements that lead to moral injury and are often tied to process measures and not outcomes.
- Entities unfamiliar with the longitudinal relationships required to impact patient behavior (and thus, outcomes) create standards that impair that relationship.
- The lack of focus on clinical risk of a population and perverse incentives tied to volume often neglect the neediest group of patients.
- At a systems level, the lack of a well-defined population health strategy does not tightly bind outpatient care managers to their primary care clinic teams that they are supporting, leading to siloed, marginally effective care at best. Care management disconnected from primary care is highly ineffective at improving patient health risk.
Kathleen Dalton, RN, CCM, CMGT-BC Kathleen.Marie@converginghealth.com
Michael Tuggy, MD MTuggy@converginghealth.com
Scott Conard, MD Susan Lindstrom Laurence Bauer, MSW, MEd
scott@scottconard.com slindstrom@mypha.com laurence.bauer@gmail.com