COVID has brought significant change to case management practice in Texas as well as the entire country.
The first wave of COVID drove dramatic increases in COVID hospitalizations and increased utilization for those patients. Many healthcare systems struggled with bed capacity, equipment and staffing to provide effective patient care.
The acute care setting saw the largest immediate impact. With all elective surgeries and OP procedures cancelled, many people did not seek care unless absolutely necessary. Patients avoided emergency departments for fear of catching COVID. While hospitals were scrambling to find staff to cover census, OP settings such as ambulatory surgical centers and physician offices were closed. The pandemic provided a catalyst for physician offices to provide telehealth services for their members that needed care. Adoption of telehealth was swift. A recent study of telehealth use in Texas found that 4.5 million Texas patients began using it during the crisis. Nearly 94% of the respondents said they would use it after the crisis, and 45% said they now trust telehealth options as much as or more than an in-person visit. (https://www.tahp.org/news/532372/-COVID-19-and-the-Growth-of-Telehealth-in-Texas.htm.)
Case managers who practiced in the acute care setting revisited how they approached their roles. Transition of care and discharge planning became top priority challenges for case managers. Long-term acute care (LTAC), skilled nursing facilities (SNF) and nursing homes would no longer accept new patients with COVID, making placement and discharge for COVID patients more difficult. Bed capacity and hospital census were negatively impacted. Home health and DME requirements for discharge to home saw new challenges. Many agencies would not service new COVID patients, and oxygen was in short supply despite high demand particularly for patients with high oxygen requirements. Again, the negative impact on hospital census remained high and the daily influx of COVID diagnoses made moving patients along the continuum increasingly challenging.
Discharge planning has improved since the lockdown. Case managers must continue to know their extended providers well and understand the quality of care that patients receive from them. Collaboration with case managers and providers is more important than ever.
Many insurance plans waived the requirement of a three-day inpatient stay prior to SNF, which was a positive response to COVID. However, it was still challenging to find a facility to accept some patients. Discharge planning became an increasingly important task for case managers. With vaccines now available, we’ve seen improvement in these discharge planning challenges. The biggest emotional challenge for case managers was working with patients who were very ill or facing end-of-life situations, who were restricted from their family during this very fragile time. The case manager had to provide the dual role of support for the patient and the family, a heart-wrenching situation. Now many facilities are allowing one family member to be with a patient, but are very strict in monitoring the situation. Case managers need to watch patients closely and recommend referrals as appropriate to the physician for additional services for patients and families. In the aftermath of COVID, it is important for case managers to take care of themselves both mentally and physically.
Health plan case managers are faced with different challenges. Offices closed promptly and all staff began working remotely, presenting many case managers with a completely new work environment. Their patients were transferred between facilities because some facilities did not have bed capacity for patients. Authorizations were no longer a requirement, and services were approved for in- and out-of-network services as requested. Case managers worked diligently to follow their members through multiple facilities and levels of care to facilitate discharge planning and work collaboratively with hospital case managers. In addition, many states required additional reporting that many times required manual processes. Utilization rates were lower due to the elimination of elective surgeries and suspension of face-to-face visits. Some organizations introduced virtual visits, while most work was completed telephonically. Medicaid members requested services such as personal protective equipment (PPE) for their personal attendants.
On a positive note, some populations such as asthmatics experienced improvement in their health status. Asthma hospitalization decreased dramatically as their exposure to triggers and environmental factors during lockdown were minimized.
Health plan case managers now need to focus on their members and getting their members any services that may have been delayed or canceled.
Advancements in innovation and technology for the case management industry is the positive change that has come out of COVID. Many case management services that previously required a face-to-face component advanced with the use of virtual visits for following and managing their members. Workers’ compensation advanced rapidly with telehealth, tele-rehab and virtual visits. Many Medicaid programs also utilized virtual visits. Futuristic case management services will probably include a hybrid model of both face-to-face and virtual visits.
Cancer preventive screenings were canceled for months. It will be important to facilitate care for the members to get the screening scheduled as quickly as possible and immediate access to care if there are positive screenings. Another area to monitor will be access to behavioral health services. Although shelter in place was intended to protect us from COVID, the social isolation has led to increased alcohol consumption, abusive relationships and increased risk for suicide. Millions of people in the U.S. were laid off, and unemployment was at an all-time high. Services such as vocational case management for workers’ compensation patients could increase dramatically in the future.
Patti Grady, MSSL, RN, CCM, CCP, CMCN, has been an RN for three decades and worked in the case management industry for more than two decades. She earned her master’s degree in strategic leadership from Mountain State University and her bachelor’s degree in nursing from Azusa Pacific University. Patti became certified in case management in 1993 and has obtained her certification as a chronic care professional and in managed care.
Previous work experience includes health plan commercial case management; hospital case management; a Medicare demonstration project and Texas Medicaid. In her current role, Patti is the clinical program director for Axispoint Health providing condition management services for a Texas Medicaid health plan.