Case Managers and Healthcare Reform. A Greater Role?
June 29th, 2009 It should be an exciting time for case managers. Healthcare reform is in it’s creation and The RAC (is it not the perfect nom de guerre?) is knocking on our doors. Yet I hear nothing from our ranks or leadership weighing in on the issues.President Obama recently made notice of an article in the New Yorker by Dr. Atul Gawande. This article was about a Texas city that had the highest cost per Medicare patient in the US. It’s conclusions said nothing that any nurse case manager could not have told him about over utilization. The reform issue of “how are we going to make universal healthcare affordable?” is all about case management principles. If the future of healthcare delivery is going to be based on the principles of the right care and the right time, it is going to take case managers to make it work. Focusing on the here and now, The RAC is the best thing ever to happen to hospital based case management. Hospitals will not be able to survive without strong UR/ case management programs.
Ray Gridey, RN BS, CPUR – Case Manager
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I am in need of a generic care plan for care managers to send to physicians once member of an HMO agrees to case management. Looking for chronic care for adults.
Initially, I am skeptical as to how the role of the CM will ultimately be re-defined with the healthcare reform. Having worked as a hospital-based UR/CM; I have first handedly seen the effects of over utilization, poor patient care management as well as little resource management. Patients and their families are much more aware of their rights and expectations have increased tremendously. The consumer is now very educated, and very savvy. They are equipped with the latest operations, testings and alternatives…thanks in large part to the internet and TV advertisements. However, in my experience sometimes too much information is not necessarily a positive entity in DCP. Patients expectations are formed from the perspective of “what I am entitled to” not “what is best for me in my current situation”. Patients have a cookie-cutter mentality when it comes to discharge disposition. This is also largely fueled by MD’s who wish to make their patients(a.k.a clients)happy. In this competitive environment; a referral base is required to sustain a medical practice. So, physicians ( in my experience) have tended to acquiesce to the patient’s wish without explaining the parameters by which it will occur. They sometimes unknowningly place unreachable goals for the patients and their families; and as part of the DCP team, we are placed in the uncomfortable , awarkward position of deflating their hopes. Many feel that the rules dont apply to them if the MD is in agreement w/them…they fail to realize that ultimately the MD has little understanding of the process, rules & regulations that govern the acceptance into any facility. With this in mind the “principles of right care for the right patient at the right time” is aptly met with the tinely intervention & acceptance of the CM judgment. If MD’s deferred to us for the final reccomendation for disposition….healthcare would indeed have truely been reformed.