Case Management and Value Based Care
Linda Van Dillen, VP of Communications and Chief Quality Officer, CompAlliance Twitter @CompAllianceRN
CompAlliance, like the rest of the workers’ compensation community, is currently looking at the definitions and iterations of value-based care systems. One of the initiatives we will be addressing this year is the role case management could play in a value-based care system. As part of our research I listened to an excellent WCRI webinar on value-based care. The presenter discussed in broad-brush strokes the financial risks Accountable Care Organizations and others with value-based, capitated payment arrangements in the personal healthcare environment experience. One common intervention suggested to minimize financial risk in these payment models was the implementation of case management services. Though these type of payment models aren’t currently being used in workers’ compensation, the same financial risks would be applicable, if they were.
In private health care one of the biggest drivers for financial risk for these types of programs is the impact of social factors as a barrier to the member’s health. This should not be a surprise to the workers’ compensation industry as we are beginning to acknowledge and understand the impact of these social determinants of health (economic stability, physical environment, education, food and housing security) on healing, rehabilitation and the ultimate return to work for our injured workers.
A recent CCMC Issue Brief, dated December 2018 states, “In the transition to value, case management builds the bridge to whole-person health.” Vivian Campagna, MSN, RN-BC, CCM the CCMC’s Chief Industry Relations Officer states, “There are cultural and resource limitation hurdles to overcome but identifying and connecting clients with important community services can be accomplished effectively, particularly with a case manager.”
The article goes on to quote Bonnie Ewald, who agrees with Campagna. Ewald is the program manager of strategic development and policy for social work and community health at Rush University Medical Center. She manages program development and advocacy initiatives aimed at integrating health care and social services at Rush and across the country, including leading the Center for Health and Social Care Integration, which serves as a national technical assistance hub to advance practices that break down barriers to health.
Aligning financial incentives to rewarding integrated practice – a model that considers how mental, physical and social well-being relate to health is not easy under current payment models. The question is asked, “How do you move towards value in a system where volume is still rewarded?”
As case managers we sometimes find it hard to define our value when the interventions we provide enable us to maintain an effective level of communication that prevents a complication or delay in treatment from happening. I recently addressed this challenge in an article I posted May 1, 2018. In this article I was responding to a post from a file review company citing statistics that supported their opinion regarding the lack of effectiveness of case management on workers’ compensation claims. My conclusion in this article was when looking at the impact of case management you should look at the absence of complications, extended treatment and deviation from evidence-based treatment along with facilitation of effective communication between all parties throughout the life of the file.
While those are all pertinent measures, I think I only addressed half of the picture at best. According to Ewald we as case managers need to develop a business case to define the value of case management in terms that the payers of our services and the providers can understand. “We need to demonstrate the value of the skill set we bring to the table.” I would add to do this statement …”within the workers’ compensation setting and define the activities, tasks and services that result in improved patient outcomes.” We also need to consistently define client risk factors to target in our case management interventions.
At CompAlliance we train our nurses in Ethical Decision Making, Cultural Diversity and Motivational Interviewing techniques to assist in engaging in and addressing barriers to care and resolution of the claim. These skills also facilitate developing the relationship with the Injured Worker that assists them in helping to navigate the complicated workers’ compensation system. We collect feedback from the Injured Worker at the time of file closure. This is a qualitative measurement, however, and doesn’t address quantitative savings that are equally as important when addressing value-based care systems.
As case managers when we receive a referral, we initiate the case management process by reviewing the medical records prior to our initial engagement with the injured worker. At that initial point of contact with the injured worker, we then begin to build rapport and learn about their preferences for care by performing a comprehensive biopsychosocial assessment. The case manager then begins with the goal-setting process, working towards facilitating self-efficacy of the injured worker. We then continue to engage all stakeholders throughout the treatment and rehabilitation phase of care until all goals are reached.
As case managers we will continue to support a person-centered approach to healthcare. We need to get better at defining and tracking the value proposition for case management as an important component of any value-based care system workers’ compensation programs implemented. In the meantime, one of my goals for 2019 is to research methods to better measure and quantify the value of case management within our current system. If a value-based payment model for workers’ compensation is ultimately implemented, case management and the benefits we effect, will then have an important seat at the table.