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Why The Chronic Care Model of Case Management is Destined for Failure

1. The case load of the Case Managers (CM) is too high.

a. A case load above 50 is not case management, it is care coordination, an attempt to clean up after a health event has occurred in someone who is a known high risk for hospitalization/ER visits, etc.

b. Case Managers need some “unproductive” or non-billable time to team build, to learn how to strategize particularly difficult clients as a group and keep up with new approaches to manage chronic illness. Further, case/care management teams need to build in ways to manage the stress of dealing with difficult distressed clients and situations

2. The skill set of most care managers in this setting is too low.

a. The ideal CM is an RN with a strong clinical background so as to assess patient function, motivations, and the natural course of chronic illness.

b. Use of an LPN or medical tech is insufficient unless directly supervised by a nurse case manager on the case

c. Ideally the treatment approach should be rehabilitative. This helps clarify treatment goals and strategies based on function and quality of life.

d. Case/Care Managers need to know what goes on in the community. Knowledge of the capability and quality of various nursing homes, home health agencies, etc. hinders appropriate referrals in post-acute care.

3. The incentives for efficient CM are troublesome.

a. Lowering costs while improving treatment adherence is fraught with ethical pitfalls and moral hazard. A focus on the appropriateness of health interventions requires that the care rendered actually solve the problem and meet the patient’s self-defined goals. Otherwise, the care is inappropriate, and is therefore not a covered service under the health insurance contract.

b. CM is complicated. Those who don’t know anything about managing complex illness, counseling human beings, and families, knowledge of how the health system operates, etc. don’t appreciate it.

c. The C-suite administrators of care management typically know little about Care/Case Management. Resource allocation for staffing, credentialing, and training falls short because there is insufficient appreciation for the
complexity of the task. Even doctors don’t understand the practical issues involved with CM and are not trained or socialized to understand or value non-clinical factors that impact successful CM or the health outcomes of individual patients.

d. The culture of an organization needs to have a coherent and clear vision
about how to make its mission work. Program goals need to be clearly
defined, and this focus needs to be carried out by the CM with each client
as reflected in the individualized Plan of Care,

4. Telephonic strategies to manage care haven’t worked.

a. Over the years many studies have shown that telephonic case
management is unable to significantly manage the costs of care or
improve the outcomes. There are many reasons for this: patients don’t
answer phone, find the calls from a case manager annoying or intrusive,
or just fail to keep the case manager updated when there is a change in
their condition.

b. Face-to-face via skype-type utilities may prove beneficial IF there is trust
in between the case/care manager and client/family.

5. Information Technology usability is not there yet.

a. Even though Electronic Health Records are now mainstream, lack of
connectivity continues to impair care coordination and efficient care. Care
management and care coordination are hampered by connectivity issues.
Health information Exchanges are woefully inadequate in most parts of
the country. Patients are not signing up to provider portals despite federal
mandates to do so.

b. Most providers view patient records as if they own them and are not keen
to expend resource dollars to share information with patients and other
providers not in their network. Most record transfers are still paper and
fax.

c. EMRs produce a lot of data, but not much information. A clinician is not
going to wade through reams (or on-screen rivers) of computer-generated
narratives, lab values or daily notes, especially if those notes repeat
previous findings. There continues to be a cut-and-paste practice in EMRs
by clinicians that fills space, justifies billing codes, but does not truly
reflect the status of the patient or enhance the Plan of Care.

6. Customer service in health care is terrible.

a. Provider organizations are having a difficult time adjusting their cultures
to make up for the heightened expectations of patients and their families,
distrust of health providers and frustration regarding health insurance
coverage.

b. The Case/Care Management system needs meet internal and external
stakeholder needs and expectations. Connectivity issues continue to
hamper care coordination.

c. The Case/Care Manager must have sense that the job is doable,
meaningful, and valued. CMs are often placed in double-bind situations
where there is no win-win, and they received the brunt of the blame.

7. Dementia, Dementia, Dementia

a. Most people with chronic illness have at least a mild cognitive
impairment. Those that have 3 or more health problems certainly
demonstrate loss of cognitive function, judgment and independence, but it
is not diagnosed by a physician or addressed in the Plan of Care. This is a
mistake.

b. There is a strong link between memory issues and drugs, both
overmedication/sedation or lack of adherence. Medication given for
dementia usually has more problematic side effects than improvement in
cognitive function. Use of benzodiazepines, alcohol and pain medication
are a major risk factor that is generally not acknowledged in the
individual Plan of Care.

8. The family is not in the loop.

a. The CM needs to “manage” the family, not just the patient/client. The
families need attention and coaching to enable the patient to value and
adhere to the Plan of Car. The family needs to watch (and know what to
watch) for changes in symptoms or behavior, and alert the CM. The family
needs to be part of any discussion regrading the Plan of Care. The CM also
needs to manage family expectations regarding the likely prognosis of the
patient and their expectations of the heath care system.

b. The CM needs to know the value system of patient and family. This is
lacking unless there is a face-to-face meeting between the CM and the
patient and family. Language, cultural and spiritual issues need to inform
the nuance of the Plan of Care to insure success.

c. The CM needs to engage family support to assure adherence to the POC,
with early notification if the POC is not working.

9. You can’t Case Manage everybody!

a. 80/20 rule: It’s commonly known that in case or care management 20% of
patients Account for 80% of resource use. Some data shows that 10% of
individuals account for 50% of costs. The key is to identify those patients
that are most likely to fail. The medical model would dictate that those
were the highest utilizers the of Health Services that would benefit from
case management is diagnosis driven, not care driven. The payment
system in health care, being an insurance model, has always skewed to
paying for procedures, not care driven. Both approaches are fatally
flawed. A Care Management initiative focuses on what care (often nursing
care) is appropriate for each individual and makes it happen in a timely
fashion.

b. Identifying high-cost patients: In western medicine we’ve gotten very
good at manipulating a patient’s biometric data. We can affect a patient’s
heart rate, blood pressure and lab values. We can expertly take out your
gallbladder and replace your hip. But manipulating vital signs or adding
and subtracting body parts often have little to do with actual functioning
as it relates to health. A more potent predictor of future need for Health
Care Services is psychometric data. Is the patient in pain, is the patient
depressed, is the patient functioning in a role that would be normal for
him or her? More importantly, how does a patient self-rate their own
health? Those who self-rate their health poorly, complain of depression or
low energy or are socially isolated are much more likely to do poorly in
the Healthcare System. They require the services of a well-qualified CM to
assist in deciding what Plan of Care most likely meets their ability to
engage in the treatment plan successfully.

10. Mental & Behavioral Health: The Elephant in the Room

a. Taking on risk to deliver health services requires attention to mental
health and substance-abuse issues, not just the medical diagnosis. The
current opioid crisis brings this issue front and center. An integrative
model addressing the medical, psychiatric, and behavioral health issues with those who have chronic health problems leads to a more
comprehensive evaluation, so that planned interventions can provide
workable and coherent solutions to patients’ complaints of pain and
psychic distress. Integrating medical, behavioral and psychiatric treatment
demands a new model of how we interview patients obtain the medical
and social history.
Chronic illness in adults is strongly tied to adverse childhood experiences
(ACEs). Physical, sexual and emotional abuse, mental illness and/or
substance in the family and abandonment by death or divorce cause
immune system abnormalities which manifest as chronic illness in adults,
e.g., hypertension, chronic pain, diabetes, morbid obesity, depression,
cancer, diabetes, substance abuse and autoimmune disorders. We need to
appreciate each patient’s past history and ability to cope with such
stressors if we have a hope of successfully addressing their chronic illness.

b. The Plan of Care for chronically ill patients should be focused on function,
safety and Quality of Life (QOL), not a cure. By definition, chronic illness
has no cure, but 80% of the health care dollar is spent on chronic illness.
So, if we’re to manage chronic illness, we need accurate risk appraisal for
each patient, preventive services moderate those risks, and early
recognition of the symptoms of chronic disease or any loss of function
during the progression of aging and chronic illness. The goals of health
services should then shift to interventions that slow the progression and
loss of function that is incurred by a chronic illness. Right now, our Health
Care delivery system is unable to enable strategies that would identify or
moderate the health risks of those individuals are a high risk of
debilitating chronic illness. Health costs in the U.S. are not going to be
significantly moderated until our systems of care confront this reality.

Posted in Agencies & Facilities, Elder Care, Healthcare Advocacy

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Presenting in Las Vegas

We are proud to present at the Navigating the Full Spectrum of Case Management, June 10-14th in Las Vegas, NV. 

Please join us at this exciting event!

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Do You Have The Guts?

The gut microbiome, the roughly 10 trillion to 100 trillion bacteria and other microorganisms
that live in the digestive tract, contributes to health by synthesizing vitamins, metabolizing drugs
and fighting pathogens. Anything that disrupts the balance of microorganisms, such as
antibiotics, which can kill both “good” and “bad” bacteria, has the potential to cause disease.
Data from a 2016 study suggest that exposure to antibiotics in infancy can alter the gut
microbiome and weaken the immune response for years to come. Other studies have linked the
use of antibiotics in children to an increased lifetime risk of asthma, obesity and inflammatory
bowel disease, effects thought to be mediated by the gut microbiome.

Antibiotics can also have long-lasting effects on adults. Researchers at Stanford screened more
than 900,000 genetic samples from the stool of healthy men and women who took the antibiotic
ciprofloxacin. They found that most of the gut microbiome returned to normal after four weeks,
but that the numbers of some bacteria still remained depressed six months later. In a longer,
larger follow-up study, they concluded, “Antibiotic perturbation may cause a shift to an
alternative stable state, the full consequences of which remain unknown.”

In an example of a potentially beneficial effect of altering the gut microbiome, evidence suggests
that antibiotics can suppress the formation of a molecule in the gut that increases the risk for
heart disease.

The National Institutes of Health Human Microbiome Project is using advanced genetic
techniques to sequence all the genetic material of the gut microbiome. As newer data becomes
available, a nuanced understanding is emerging: Antibiotics may exert both beneficial and
harmful effects on the gut microbiome.

Posted in Consumer News

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The Forces Behind Our Opioid Crisis

If you can’t trust your pharma rep, who can you trust?

istock.com/Pureradiancephoto

Purdue Pharma spent millions marketing the drug that has led to today’s crisis. istock.com/Pureradiancephoto

The US uses 80% of all the prescription opioids in the world, with only 5% of the world’s population.  This does not include the street equivalents (heroin, fentanyl). The lack of controls for this drug, on the production, distribution and dispensing has led to the alarming addiction rates for legitimately prescribed and illegitimate narcotic use. Suddenly there is alarm because over 64,000 people die in the US due to opiod overdoses per year. That is more than five times the number of gun murders and more than three times the number of suicides in the US per year.

Twenty years ago…

While I was still doing some ICU nursing, I attended an in-service training covering, among other things, a fairly new drug called Oxycontin. This drug claimed special powers, a timed-release version of Oxycodone (think Percocet, Vicodin) that would gradually release the pain-killer over 12 hours. The company, Pharma, claimed their formulation made Oxycontin addiction-proof.

I was concerned because when I looked the drug up in Drug Facts and Comparisons, it appeared that the equivalent of 10 mg of morphine was contained in every mg of “Oxy,” as it became known. So 10 mg of Oxycontin would be 100 of Morphine! Given every 12 hours as directed, the patient with the lowest dose of Oxy would get the equivalent of 210 mg of Morphine (or Morphine Milligrams Equivalents, MMEs) a day!

A drug rep came to the hospital to answer questions about Oxy. I asked the drug rep about the addiction risk. ‘Oh, it’s easy to wean off, you just halve the dose each day until you wean it off. There’s no residual craving.’ This was a lie, of course, but in 1997 it would be difficult for an individual clinician to know what a disastrous outcome was unfolding regarding prescription narcotics (see chart of opioid use disorders below). Oxycodone and Oxycontin are the real gateway drugs leading to heroin abuse and overdoses. The sales of privately-held Purdue Pharma have landed one family on the Forbes richest families. What a legacy!

BCBS Opioid Use Disorder Rate Per 1,000 Members for Past 7 Years

BCBS Opioid Use Disorder Rate Per 1,000 Members for Past 7 Years  Source: Blue Cross Blue Shield Health of America Report

Currently the CDC recommends no more than 50 MMEs per day to address chronic pain, and does not recommend the use of sustained relief narcotic analgesics at all. This refers to those who do not have active cancer or are in a palliative care or hospice program.

Illegal Marketing Tactics

Compounding the problem is the unprecedented Oxycontin marketing push by Purdue Pharma. Starting in 1996, the company spent millions promoting to and “educating” doctors – using data to identify those who’d likely prescribe high amounts of the drug. They more than doubled their sales force and highly incentivized their reps – paying out some $40 million in bonuses in 2001 alone. Purdue also skirted FDA marketing regulations by sending out 15,000 educational videos that minimized addiction risk to doctors without first getting FDA approval. Sales grew from $48 million in 1996 to almost 1.1 billion by 2000. In 2007, three company executives ultimately pled guilty to criminal charges of misbranding.

Sun belt and rust belt states have the highest prescribing rates for opioids. In 2012, health care providers in the highest-prescribing state wrote almost 3 times as many opioid prescriptions per person as those in the lowest prescribing state.

How Insurers Are Part of the Problem

The New York Times has reported that insurers are making it harder to get non-addictive, pain-relieving drugs because they’re more expensive.  Private pay and Medicare insurers require little or no pre-approval for drugs like long-acting morphine or even Oxycontin, and less out-of-pocket co-payment. This steers people suffering from chronic pain toward these habit-forming drugs.  Patients have been left in a lurch after some drug companies stop covering drugs that are working for them.

To add insult to injury, the article reported that insurers are also making access the addiction treatment drugs difficult.

After Overdoses, Doctors Still Prescribe Opioids

According to the Journal of American Medicine, for every 1 overdose, there are 30 non-fatal ones – which represents an intervention opportunity. But, there is evidence that doctors are missing opportunities on many fronts. A 2002-2012 study in Pennsylvania reported high rates of post-overdose opioid prescribing. Another study showed a low rate buprenorphine treatment – which is one way to fight addiction. These studies were conducted with commercially insured patients. Little is known about Medicaid enrollees – who are at 3 times higher risk for overdose.

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Presentation: How To Never Lose An Insurance Appeal

2 Upcoming Dates and Locations

Newell-Headshot

 

Presented by Michael Newell, RN, MSN
with Jodi Bouer, Esq.

Increase your understanding of insurance plans, benefits, eligibility, industry jargon and all the players who contribute to decisions about coverage.  The politics of insurance coverage are complicated, but they’re not insurmountable.

Arm yourself with the knowledge and tools you need to win your appeals or to assist clients with whom you work.

 

Presentation Dates

How To Never Lose An Insurance Appeal

Thursday, September 7, 2017

CSMA Logo NoBkgSeptember meeting of the Mid-Atlantic Chapter of the Case Management Society of America

Double Tree-Hilton
640 Fountain Road
Plymouth Meeting, PA 19462

  • Registration begins at 5:30pm
  • Buffet Dinner 6:00pm
  • Business Meeting at 6:15pm

2 CCM CE credits, good for RN credits in New Jersey and Pennsylvania

To register, visit: cmsaphilly.org.


How to Never Lose An Insurance Appeal

Tuesday, September 12, 2017 | 5:30 PM
Kessler Rehabilitation Institute
62 Brick Road, Marlton NJ

MUST RSVP in advance to Donna Sobel
Email:  dsobel@kessler-rehab.com

2 CCM & RN CE credits


 

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