Using Care Management to Develop an Aging Plan

Posted by Donna Mae Scheib on March 05, 2019

Using Care Management to Develop an Aging Plan

When you first hear the term “care management”, you probably think that it generally describes communicating with medical professionals about your healthcare and planning future courses of action. This assumption is right, but a closer look shows that care management has very particular advantages and limitations for patient populations.

The Robert Wood Johnson Foundation defines care management as “a set of activities intended to improve patient care and reduce the need for medical services by enhancing coordination of care, eliminate duplication, and helping patients and caregivers more effectively manage health conditions”. In other words, care management is the middle ground between hospital and home. For patients with complex health needs, the home and workplace are an additional care environment. These places are where care managers check-in, coordinating care in teams by communicating about patient needs that would have otherwise required a clinic or hospital visits.

Patients with complex health needs include senior citizens, disabled people, and chronically ill people. Due to its reliance on education and planning, care management can help you address most any health need that does not require immediate care. Some of the common health needs to be addressed under the banner of care management include:

• Medication
• Nutrition and dieting
• Chronic pain and chronic illness
• Diabetes
• Heart conditions
• Arthritis
• Alzheimer’s Disease
• Therapy and palliative care
• Patient education
• Risk stratification
• Navigation of the healthcare system, financial resources, and advance care planning

The Institute for Healthcare Improvement defines its Triple Aim as “improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care”. Care management is a recent healthcare delivery system designed to meet these standards, but significant costs remain as the next section will describe. This article will explain why and how you should consider pursuing care management if you have complex health needs.

Costs and Benefits of Care Management

The previously mentioned Robert Wood Johnson Foundation study states that care management programs have been most effective for patients returning home after hospital stays. These programs have reduced costs and hospital readmissions because the patients received guidance on taking care at home to avoid future costly stays at the hospital. However, the Robert Wood Johnson Foundation study also found that care management did not significantly reduce costs under other circumstances. As such, care management is only recommended for patients whose complex health needs put them at risk of readmission.

As far as care management programs’ success in preventing readmissions is concerned, Improving Primary Care reports that “one-half of patients readmitted to hospitals within 30 days of discharge has not seen a community provider”. According to the article, this readmission rate is why practices most commonly recommend care management to high-cost, high-utilization patients.

The main benefit of care management is its improvement of a patient’s quality of care, which the Robert Wood Johnson Foundation study found was a consistent result of even the programs that did not reduce costs. For an idea of how this improvement looks on an individual level, Health Catalyst’s stories about coordination of care and communication with patients describe how the extra communication that care management provides on all levels causes measured improvements. Patients risk complications in care coordination’s absence and become more receptive to caregiver advice in its presence, all because care management facilitates caregivers’ communication among patients and fellow caregivers.

With these reasons on whether or not to consider care management in mind, the next section of this article will explain how to tell if a given program meets the Triple Aim standards.

How Care Management Works

The cost and effectiveness of a care management program for a patient ultimately depend on its cost and effectiveness for the practice. The number, work hours, and training of staff, the practice’s revenue from billing and funding, and the characteristics of the full patient group all determine the practice’s ability to deliver high-quality care management. If you are interested in seeking care management near you, you can trust that a care management program is at its most reliable if it claims to involve all of the following:

• In-person communication between care manager and patient, typically at home
• Coordination of care between a patient’s care manager and primary care physician, including the selection and review of patients
• A team of registered nurses (RN) serving as care managers under a light workload, alongside social workers if possible
• Training of patients and care managers to identify health risks at their earliest stages
• Help from informal caregivers for patients with cognitive or physical difficulties

According to the Robert Wood Johnson Foundation, care managers meeting their patients in person succeed whereas care managers who only talk to patients over the phone do not. This is because care management, at its most patient-centered, makes the healthcare system feel less distant and intimidating. The closer a care management program is to the above bullet points, the more patients will feel and become in control of their health.

Practices currently have a few ideas as to how their care management programs can better meet the Triple Aim and the above bullet points. Many of them aim to improve their analytics so that they can reduce costs to all parties and recognize which patients would benefit from care management. Because care management is an intermediate step between hospitalization and less frequent monitoring by a medical assistant, primary care providers may help you decide which of these options may benefit you most. They may assess you on your physical activity, diet, support system, finances, transportation, and other living conditions to make this determination. If this article has convinced you that care management could benefit you in the foreseeable future, though, you should consider mentioning it on your own.

If you are interested in seeking a care management program in the immediate future, Senior Living Link provides a list of organizations in our Private Home Healthcare Agency, Visiting Home Healthcare Agency, and Visiting Home Healthcare Agency - Hospice directories. The search results of this international selection can direct you to care management services in your local area.  

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