When you have a population that is heavily weighted with older adults and patients with chronic illnesses, it is difficult to assure that the physician’s plan of care will actually be implemented in the home setting. This often leads to mismanagement of health care needs in the home and the increasing incidence of excess disability and repeat healthcare crises within your patient census. This lack of control in the home environment can be both frustrating and costly for physicians, health plans, hospitals and patients.

Private care management is a service that has evolved over the past twenty five years to address just these issues and to help the healthcare system better meet the needs of patients and providers. This is achieved by following the patients across multiple settings and assuring the coordination of care and communication among the various providers.

Differentiating Care from Case Management

Historically, case management has been a function of third party payers to provide financial gate keeping services in parallel to healthcare provision. This was rooted in a medical model of funding that was triggered by an acute medical episode requiring intense short term medical care, rehabilitation and a return to function. Because there was an expectation that the individual would regain all or most of their prior functional status, there was little need to focus on the broader psycho-social-behavioral issues in the person’s life.

However, as medical advances have made most illnesses into chronic diseases, this combines with the growing age wave to make a more comprehensive, individualized and consumer centered plan of care an essential component of successful healthcare delivery. It becomes more important to treat the whole person and his/her support system in order to have a compliant patient who is a partner in care.

Private care management, therefore, evolved from this more comprehensive perspective of partnering with the patient, the caregivers, community resources and legal and financial advisors to address the full spectrum of needs of the care recipient. This bio-psycho-social-environmental approach is more appropriate for an aging population with chronic care needs who often cannot advocate for themselves. Assistance for decision making about end of life issues, care alternatives and surrogate care givers may also trigger care management. Pro-active intervention by a care manager in partnership with the care recipient and the family can lead to better compliance, intervention before a crisis and stabilization of the physician’s plan of care.

Physicians and Private Care Managers: A Natural Partnership

Care Managers have been relatively successful at partnering with attorneys, trust officers, assisted living facilities, public and private agencies to meet the needs of older adults and persons with chronic illnesses. It has been more challenging to partner with physicians and hospitals because there is not a funding stream through traditional Medicare or HMOs for a bio-psycho-social approach to care management. However, families are willing and able to pay for services if it saves them time away from work and the travel expense that long distance caregivers experience.

Increasingly physicians and discharge planners are aware of the fact that patients cannot be responsible for the implementation of a plan of care without assistance from a family or professional caregiver. Often the chronic nature of care exceeds what a Medicare home health agency can do within their limited episode of care. It is also beyond the skill and training level of a privately hired aide. These tasks include supervision of in home staff, medication management, assuring that follow up medical appointments are kept, providing emotional support for dealing with losses, environmental safety to prevent falls, reviewing routines for appropriate nutrition and hydration, relating to out of town families about the needs of the care recipient, assuring the use of community services (such as VA benefits, day care and meal programs), assuring that finances and legal issues are handled properly by professionals, and the coordination of all services to avoid overwhelming the patient.

Benefits of the Care Manager-Physician Partnership Patients return for follow up visits, as recommended; On-going medication management in the home; Monitoring for safety and fall prevention; Supervision of in-home staff; Coordination with other allied health professionals; Monitoring of nutrition and hydration; Assuring use of community services and benefits; Assuring that legal and financial planning needs are addressed; Emotional support for coping with losses; and Liaison to and support for family caregivers.

One of the many benefits of working with a care manager is that s/he will be able to see changes in the patient and help to assure medical intervention prior to a crisis. With regular visits from a professional in the home, Rona Bartelstone Care Management has experienced many situations in which there are health, mental health or functional changes that are not reported by the elder, but that are indicative of the need for immediate medical or social intervention. The care manager can alert the physician and the family to assure that appropriate care is provided and the crisis averted. When the crisis does come, the care manager can assure that family is kept informed, and that medical care is provided in a timely manner.

Care managers and physicians together can provide a more comprehensive service to our elders than either can achieve alone!