Case Managers are professionals who prevent patients’ needs from slipping through the cracks while keeping an entire care team in the loop through effective communication. When working in the primary care setting, quality care measures are more important now than ever before due to changes in reimbursement. It is very challenging to educate and assist providers who have been practicing for 10 + years in transitioning to value-based care instead of fee-for-service. It takes a case manager-led team approach to transform a clinic to implement quality measures from the receptionist to the provider. Measuring the worth of a case manager is challenging, but with the help of accountable care organizations, providers can see cost savings and losses plainly written which proves case managers’ worth and need.

Case managers are at the forefront of quality measures in the clinic. From ensuring compliance with screenings to medication adherence, the entirety of a patient’s health is a priority. All people want a high-quality experience wherever service is rendered. Case managers are the key holders to drive the needle up in quality. What is high quality? From a case manager’s perspective, it means treating patients with the absolute best care just as if they were your own family member. Oftentimes, providers are consumed with paperwork and documentation requirements that there is just not enough time in the day to check if the next patient on the schedule is up to date on the wellness visit, screenings, vaccines, and to ask about memory concerns or fall risks. A simple screening questionnaire by the case manager can easily identify all the gaps in care and barriers to managing care. A quick conversation with the patient can also identify any need for intervention with memory concerns or falls. Let’s say a patient is a fall risk and is referred to physical therapy to improve balance. The simple referral for the patient could save thousands in hospital costs should they fall and become injured without the therapy. The autonomy of a certified case manager with a background in healthcare is invaluable and provides an additional resource to the clinic to drive up those quality measures.

Case Managers are a muffler for the grumbling of many providers when it comes to additional tasks to improve quality. If a provider is told to add documentation that is required for insurance or to fill out that extra form to earn that bonus, there is some resistance. How can one blame them? The change to value-based care is a paradigm shift. Previously, providers did not have to complete a prior authorization or document all applicable diagnoses each year. Providers were not taught value-based care in their medical training 10-plus years ago. Merging a complex business model into a medical profession of educated providers is very challenging to explain and implement, especially when it’s coming from someone who is “just a case manager”. Many diagnoses carry an amount of money with them that estimate the cost of managing that condition for one year. If a diagnosis is not documented each year, insurance will think the patient does not have that condition anymore. What if a condition worsens? The case manager, for example, can then take the initiative to point out to the provider that a patient’s GFR has worsened and now qualifies as CKD Stage 4 instead of CKD Stage 3b. If a provider is focusing on managing that fine line of a Coumadin dose, a case manager can fill in the gaps and notify the provider of missed screenings and applicable diagnoses to consider. Creating a value-based environment in a fee-for-service world takes knowledge, initiative, and perseverance. Case managers are the driving factor in the clinic to implement quality measures to improve patient care. Once those quarter results come in from insurance payers, providers can then see the worth of case managers dollar for dollar. Patients alike benefit from improved health outcomes and less healthcare spending. 

Case managers are not built to carry all the weight of quality measures. It takes a team to move forward to a value-based world. Training each part of the team can immensely improve compliance and initiative from the health care team. Receptionists can be trained to identify if a patient has had a wellness visit. A medical assistant can follow up on the recommended screenings that were due during a previous wellness visit. A provider can provide education to patients on the importance of a wellness visit in hopes patients would comply and schedule the visit. All the while, case managers are managing the patient’s care and ensure coordination is completed. 

In conclusion, case managers are the coordinator of the patient’s health. Interventions by case managers that come to mind that assist in improved health outcomes are helping an injured patient navigate through the rehab process or assistance with transportation to appointments. In addition, case managers can make sure a fresh hip replacement receives a prescription for a blood thinner or help a homebound patient receive their medications through the mail instead of at the pharmacy. There is an array of things case managers assist with, but overall, they are the core reason a patient has high-quality health outcomes. There are opportunities for all health care providers to recognize and appreciate the value of a case manager and their effect on their patients’ lives through care coordination.

I’m Kelly Archer, BSN, RN, CCM, and I have been an RN for over 11 years. I live in Tuscaloosa, AL. I have ED and case management experience and became a certified case manager in 2020. I’ve been married for 11 years and have 2 daughters, Scarlett and Tori Laine. I enjoy spending time with my family and watching Alabama football. I strive to improve health outcomes through value-based care in my profession.