September 18, 2024: The Challenge of Complex Care Management Part C
Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care – Part 21
Entities defining the work
We have much to say about pseudo-regulatory companies that create standards and processes for both primary care and care management. As these companies do not actually take care of patients directly, they are not accountable to real patients or outcomes. Far too often, these entities focus on process, documentation and frankly, make-work instead on getting direct feedback from patients, clinicians and their care teams as to the effectiveness of the process they promote. Many clinics and care management departments have NCQA certification, but their patient loyalty, engagement and outcomes are abysmal. These same care teams have a lot of choice words to describe how the certification requirements impact their work with patients. “It’s all about checking boxes not about engaging patients in what really matters,” is a common refrain I have heard when surveying care management nurses. The primary metric needs to be improved patient outcomes measured mostly by patient input and reliable data on utilization of services.
The Person-Centered Primary Care Metric, now adopted by CMS for its MCP and ACO Flex primary care initiatives, is an ideal example of a tool to measure these essential aspects of trust and relationship in primary care. A simple modification of questions would allow a care management department to get a strong sense of how the patients they engage feel about the effectiveness of their care manager.
The focus must be on building trust first, meeting the patient where they are and developing an actionable care plan that the patient can pull off realistically. Gather data shouldn’t just be a long list of questions but should involve a care review of the patient’s active problems and apparent barriers to care, then when first contact is made, the care management nurse knows the patient to a depth that instills trust because they have done their homework. When access care challenges and barriers, the SDOH relevant bits of information will come to light as to what is really impacting that patient.
Care plans are often a disaster if not written in a context of active problems, their interplay on the patient’s life, and setting realistic expectations of things the patient is willing to work on that week using motivational interviewing skills. A number of consulting organizations generate prebuilt care plans that are so generic and aspirational that they resemble emesis on paper. They are often lengthy, unrealistic, laden with platitudes, and far too many goals to be realistic. How about having a diabetic use a pillbox to help him remember to take his medications twice a day? That may be all that the patient can handle for the next month so perhaps that patient derived care plan should suffice, not a laundry list of ideals that we can generate with a Smartphrase.
It is far better to have lean documentation, a workflow and a real plan of care that is coordinated and in sync with the primary care provider’s and the patient’s priorities. Care managers can certainly enhance and inform those priorities but neither the PCP nor the care management RN should be creating a plan in a vacuum for a complex, high-risk patient. Teamwork here is essential and should be a key metric to assess the quality of CM services.
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