Primary care providers (PCPs) are in a unique position to oversee and coordinate the various aspects of a patient’s healthcare. They are the custodians of the patient’s medical history and are often the first to identify health issues that may require the involvement of specialists. By fostering coordination with specialty partners, PCPs can ensure that care is not only continuous but also comprehensive.
The new Making Care Primary (MCP) demonstration project from the Centers for Medicare & Medicaid Services (CMS) underscores the importance of initiating care coordination at this level, with a focus on supporting less experienced primary care practices in building advanced care delivery capabilities. The MCP model is a strategic initiative that aligns with the CMS Innovation Center’s Strategy Refresh and the National Academies of Science Engineering and Medicine (NASEM) report on implementing high-quality primary care. It is designed to support the delivery of advanced primary care services and provide a pathway for primary care clinicians to adopt prospective, population-based payments. This model is particularly significant as it includes components designed to improve health equity, ensuring that everyone has the opportunity to attain their optimal health. Within this model, however, the role of the case manager has not been discussed.
As we know, case managers are pivotal in ensuring that patients receive comprehensive and seamless care throughout their healthcare journey. We serve as the bridge between patients and healthcare systems, facilitating smooth transitions and continuity of care. Our responsibilities extend to discharge planning, collaborating with community resources, and post-discharge follow-up. We advocate for our patients/clients, ensuring they navigate the healthcare system effectively, and play a key role in interdisciplinary collaboration, which is the cornerstone of effective case management.
Effective communication strategies and the use of technology are key components in optimizing patient flow and enhancing care coordination. We are tasked with the delicate balance of ensuring quality care while also being mindful of costs. We play a critical role in navigating the complex landscape of insurance requirements and payer policies to ensure the financial viability of patient care.
How different my mother’s healthcare journey would have been if there had been a case manager embedded in her PCP’s practice. The referral to a neurologist may not have lain at the bottom of her purse for months because she was too embarrassed to tell anyone that she couldn’t figure out how to call for an appointment. Instead, the case manager could have secured the appointment and ensured a good handover from PCP to specialist, establishing communication lines for seamless care.
CHALLENGES AND SOLUTIONS
Implementing changes in the general approach and everyday routines of a medical practice can be overwhelming. To address this, resources such as the Care Coordination Quality Measure for Primary Care (CCQM-PC) have been developed to help clinicians incorporate care coordination into routine practice. The MCP model provides direct support to participating primary care practices and organizations to engage in practice transformation to provide high-quality primary care.
The Making Care Primary Model by CMS is a significant step toward enhancing care coordination at the primary care level. By providing primary care clinicians with the necessary tools and support, MCP aims to improve the quality of care, patient experience, and population health outcomes. However, CMS and the PCPs should be aware of the critical and crucial role that case managers play, ensuring that patients receive coordinated, team-based care that aligns with their needs and expectations. As healthcare continues to advance, the role of primary care in care coordination, supported by the diligent work of case managers, will remain vital for achieving a more effective, safe and patient-centered healthcare system.
To this end, CMSA’s cadre of CM Fellows has been hard at work, creating a position paper on the importance of case managers in the MCP Model and look to have this important piece distributed to decision-makers and participants in this demonstration project for their consideration in adding case managers to the project for better outcomes.
Dr. Colleen Morley, DNP, RN, CCM, CMAC, CMCN, CMGT BC, ACM-RN, IQCI, FCM, FAACM, is the associate chief clinical operations officer, care continuum for University of Illinois Health System and the immediate past president of the Case Management Society of America National Board of Directors. She has held positions in acute care as director of case management at several acute care facilities and managed care entities in Illinois, overseeing utilization review, case management and social services for over 14 years; piloting quality improvement initiatives focused on readmission reduction, care coordination through better communication and population health management.
Her current passion is in the area of improving health literacy. She is the recipient of the CMSA Foundation Practice Improvement Award (2020) and ANA Illinois Practice Improvement Award (2020) for her work in this area. Dr. Morley also received the AAMCN Managed Care Nurse Leader of the Year in 2010 and the CMSA Fellow of Case Management designation in 2022. Her first book, A Practical Guide to Acute Care Case Management, published by Blue Bayou Press, was released in February 2022.
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