The COVID-19 pandemic has changed how patients interact with their physicians and view telehealth, prompting health care to re-evaluate their office practices. Developing an effective case management (CM) approach should be a key component of any effort to adapt to the changing patient care environment.
Effective CM should align with the needs of a medical practice’s patients and involves developing trusted relationships with patients and providing specific services, such as coordination of care, self-management support, and transitional care. “This type of care is time-intensive and occurs mainly in between, and not during, office visits,” said Timothy W. Farrell, MD, professor of medicine and Geriatrics Division Associate Chief for Age-Friendly Care at the Spencer Fox Eccles School of Medicine at the University of Utah in Salt Lake City.
Dr Farrell is the lead author of a 2015 issue brief prepared for the federal Agency for Healthcare Research and Quality titled “Care Management: Implications for Medical Practice, Health Policy, and Health Services Research.” The most important CM strategies, he said, involve identifying patients with modifiable risks, aligning CM services with the needs of these patient populations, and identifying, preparing, and integrating appropriate personnel to deliver the needed CM services.
The brief defines CM as a team-based, patient-centered approach designed to address the increasing complexity of care in outpatient settings. In the ambulatory setting, when contending with staffing shortages, Dr Farrell said it is often tempting to ask staff to keep taking on additional tasks. “However, this inevitably leads to a vicious cycle of burnout and additional staffing shortages,” he said. “I think it is important to consider that practices are contending with an ever-increasing demand to respond to electronic patient messages.”
Increasing patient access to the care teams through electronic patient portals is a significant advance in promoting timely and patient-centered care. However, Dr Farrell said the increased access needs to be balanced with the demand it places upon clinicians and staff. “Current reimbursement models do not generally account for much of the volume of inter-visit work conducted by clinicians and staff, including especially responding to electronic messages from patients,” he said.
Compensation to support the personnel, time, and resources required to keep up with increased inter-visit work is urgently needed, he said. This could help achieve the goal of improving the care experience and improving the health of the patients at optimal per capita costs. “I also think that effective care management, exemplified by effective inter-professional team-based care, will help reduce burnout of the staff members and clinicians and restore joy in practice,” Dr Farrell said.
Due to the pandemic, self-management support is vital for patients dealing with chronic diseases and those with emerging modifiable risks. Clinicians need to make sure they understand a patient’s readiness to change so care managers can employ motivational assistance if needed. It has been suggested that private payors provide incentives to perform CM and chronic care management activities. Additionally, there needs to be an implementation of CM services across the medical landscape, including the spectrum of long-term care services and supports.
Urologic oncologist Shawn Dason, MD, assistant professor of urology at The Ohio State University Wexner Medical Center in Columbus, said the poor reimbursement for e-messaging is hindering its incorporation into practices. “It is very minimally reimbursed and that creates a real problem with managing the volume of messages since COVID-19,” Dr Dason said. “There are significant limitations in the health care workforce nationwide and without appropriate reimbursement there is no great way to integrate this increased volume into our current systems.”
The volume of e-messaging has shot up exponentially, Dr Dason added. Today, nurses, physicians, and advanced practice providers are all spending more time addressing e-messages and it is unclear if this is improving the quality of care. “Many of the messages are not covered by our current reimbursement structure,” he said. “The most appropriate thing to do in my mind is to say a provider or nurse’s time is worth a certain amount and reimburse accordingly regardless of the medium of care delivery. The professional service provided by electronic messaging is not currently acknowledged in this way.”