The following blog post was written & updated by Susan Maxsween, Vice President of Healthcare Consulting & Operations

With the growth of patient-centered medical homes (PCMH) and the push for VBP agreements in NYS, care managers are expected to serve an increasing role in managing high risk patients. Long-term transformation and healthcare delivery system reform will rely on the work of care managers within the primary care practice to achieve the goals of measurably improving the health of patient populations, controlling costs, such as avoidable hospital use, and more satisfied and engaged patients. Care managers are responsible to initiate, facilitate, and monitor specific patient activities, interventions, and chronic care protocols that will become the patient’s care plan. The role of care managers can be summarized in four tasks. To accomplish the goals and objectives for optimal health, the care manager will work in collaboration with the patient and other members of the patient’s care team.

4 Tasks of a Care Manager:

• The first task of a care manager is to identify or target high risk patients within the practice that could benefit from care management support. This can be accomplished through the comprehensive risk satisfaction tool, use of technology, analyzing data available through the electronic medical record, or by information supplied from payers. In addition, the practice’s own providers are often a source for determining the most complex patients that would benefit from coordination of services and care management. These sources can often easily identify those patients with the largest utilization of services such as those with frequent office visits, hospitalization, or emergency room visits who would likely benefit from care management support.

• The second task of a care manager is to perform a thorough assessment of the patient’s and caregivers needs and determine the patient’s goals for improving health. The assessment will review the patient’s clinical history and diagnoses as well as functional, cognitive, and mental health status. Ultimately this assessment will lead to establishment of the patient’s custom care plan and patient centered goals. The process of assessment should result in the patient being engaged in determining his or her short and long-term goals and collaborating to determine the actionable objectives and any barriers to meeting specific measurable quality outcomes based on his or her values and preferences. The plan should be developed with both the abilities and aspirations of the patient and/or caregiver and should consider any applicable factors related to the patient’s and/or caregiver’s culture and preferred language. The plan should identify and prioritize the patient’s problems, specifically address quantifiable goals to the problem(s), and outline mutually agreed upon activities to meet the goals. Timelines and methods for monitoring the progress toward the goal should be detailed. The plan should then be given to the patient and/or caregiver in writing. Training and education to the patient and/or caregiver is essential to the success of the plan. The care manager is responsible for self-management support. Patients need to be reminded of their importance in the process and be prepared for their collaborative role in the decisions needed for self management. The care manager should always consider that what they are promoting is the patient’s happiness.

• The third task of a care manager is to put the plan into action by assisting in delivering any needed interventions including education, referrals to both specialists and community resources and required testing. Community resource needs may include psycho-social support, accommodations for transportation, or auxiliary aids and other community services. The care manager should have a toolkit for facilitating referrals which could include standard forms for access to available county resources and copies of co-management agreements with frequently referred to providers. In addition, the care manager must be certain that all labs, screenings, and specialist reports are available within the patient’s record at the time of each visit. The care manager will work with the patient to use self-management monitoring tools, where applicable.

• The fourth important task of a case manager is, in collaboration with the patient, to continually reassess and adjust the plan where needed to be certain the interventions have been effective in moving the patient toward their goals. The progress can be assessed with the patient and, where applicable with the caregiver, at each encounter and/or at agreed upon milestones, but at least annually. Any barriers to meeting the plan goals should be reviewed, and adjustments made to keep the patient on track. Updates to the plan may need to be made as progress toward goals is achieved, as circumstances change, or when barriers are encountered.

Assisting patients in achieving their healthcare goals, through care management activities, will ensure sustainability of practice transformation and achievement of triple-aim goals. RMS Healthcare, with over 50 years of collective and proven care management experience in providing consulting services to our clients is pleased to provide ongoing relevant information on healthcare trends and specific transformation activities to serve our clients. For more information on how we can help your practice with practice transformation or care management activities, please contact Susan Maxsween, Vice President of Healthcare at SusanM@rmsresults.com or telephone her at 1-866-567-5422.