Constrained Innovation in Managing Care for High-Risk Seniors in Medicare + Choice Risk Plans. 5. Perspective of Care Managers


Care managers at the four MCOs talked about the differences in the goals they saw for care management, how they interacted with physicians, how they measured success, and the barriers and frustrations they encountered when trying to manage care for high-risk seniors.

Goals of Care Managers. Care managers described their role as coordinating care and advocating for patients who are sick or have functional deficits. Doing so entails coordination of both community-based social services and medical services and requires the efforts of physicians, hospital staff, emergency rooms, home health agencies, and nursing facilities. Several care managers emphasized that their function was not traditional utilization management, although they were aware that their support within the organization depended on reducing the need for expensive medical services, particularly inpatient care:

We are not gatekeepers but coordinators of care. In the event of an ER visit or hospitalization, I might visit and try to find out why that is happening and help identify resources so that the problem does not happen again.

I don’t know if we’d say that our goal was to reduce inpatient use. Rather, it is to get people to a maximum level of functioning and medical stability, which has a long-term effect on inpatient use. So our philosophy is a little bit different from utilization management. Our focus is on doing the right thing and making sure that the best care is provided because that’s more preventive and correct than worrying about cutting hospital days as a goal in its own.

Care managers also stressed their role in maximizing functional status of patients and fostering independence. However, for patients who were no longer able to live in their home, they would advise on whether an assisted-living facility or nursing home was appropriate.

Educating patients and physicians was also stated as a goal. The care managers in our focus groups indicated that patients often benefited from instruction on how to gain access to medical services and specific community-based social services that the care manager might help arrange. Patients being empowered to care for themselves to prevent future medical crises was also expressed as a goal. Patient empowerment entails both prevention and knowing how to make appropriate use of the health care system.

Care managers felt that the role they played was not understood by many doctors. In one of the case study organizations, they talked about needing to educate the health plan’s medical directors. In two of the organizations, care managers felt that their goals for care management were more long-term than those of the administrators:

We have a more personal piece to our job than many people in administration. They don’t have a relationship with the family and the patient and the day-to-day happenings that go on in our job, and I think that it is a different perspective.

Relationship of Care Managers with Primary Care Physicians. Care managers regarded the relationship with physicians, notably primary care physicians, as good but uneven, with most being supportive but others hesitant:

We get good response from most doctors. For those who are hesitant, I think the problem is that they haven’t seen that we’re really worth our salaries.

Several care managers felt that a substantial proportion of primary care physicians did not understand care management or use it appropriately. Other care managers reported difficulty getting to know the doctors, who they say often assume that the care manager will become an additional burden on their time. Good followup and rapport with the physician were important and helped generate referrals, although one care manager said that she received too many referrals. Another care manager felt that the key to getting physician buy- in was to have success with at least one patient of a given physician. Finally, care managers at Kaiser Colorado and Aspen thought that care management was needed, in part, to address discontinuities that can arise in the approaches these organizations used to deliver physician services to people in the hospital. These two organizations use hospital-based physicians to deliver inpatient care, so patients generally receive inpatient care from a physician different from their primary care physician. The additional physician involved in treating seniors required further efforts to obtain information and coordinate care.

Measures of Success. Care managers found it difficult to quantify and measure successful care management, because so much of the process is based on professional judgment. In general, they viewed success in terms of patient and family satisfaction, willingness of patients to allow the care manager to help them, belief that they had improved care coordination, and helping seniors to maximize their functional abilities. They also mentioned identifying bad health habits and getting patients into primary care promptly before they deteriorated to the point where they required extensive or emergency services.

As stated earlier, the case study organizations differed in whether the care manager made home visits or otherwise met with the patient, instead of performing care management entirely by telephone. Those who did make home visits felt that they were able to identify and solve problems that many traditional home health nurses might miss, such as a bare pantry, potentially signaling nutrition problems; a physically dangerous home environment; or evidence of alcoholism or abuse of elderly people.

Barriers and Frustrations. Care managers saw themselves as mediating between patients and families on one hand and providers and community-based social services agencies on the other. There was a recognition that all parties had to be brought together to ensure successful care management. With regard to providers, obtaining buy-in from resistant doctors was mentioned previously. Another problem is discharge planners who want the patient to leave the hospital before the care manager has been able to arrange alternative living arrangements, such as placement in a nursing home or, less frequently, a rehabilitation hospital. Arranging for admission to a nursing home for long-stay patients is difficult in some communities; one care manager reported having to call 15 nursing homes that day to find an available bed. Also, the care manager may be more cognizant than the discharge planner that the home environment is hazardous or that a patient’s dementia will require the manager to spend an extra day coordinating resources.

Care managers identified problems that arise because of the difficulty in communicating with all the other decision makers who influence a senior’s care. For example, one care manager noted that utilization review staff may terminate home health services because the patient no longer meets the coverage criteria of being homebound or in need of skilled care. Such decisions were often made without input from the care manager or without even informing the care manager in a timely manner.

Care managers in our focus groups also raised a series of organizational and administrative frustrations that can arise, including:

  • Caseloads that were too large, which made it hard to be proactive with patients

  • The volume of written documentation that is required (although care managers hastened to add that documentation was a necessary part of their jobs)

  • Inadequate secretarial or clerical support, resulting in too much paperwork for the care managers

  • The necessity of staying abreast of new technologies introduced within the managed care organization, such as computer developments and internal system changes

  • The need on occasion to interpret complex Medicare coverage rules that often seem overly restrictive, such as those that do not cover both wheelchairs and walkers for the same patient, even though patients in transition might benefit from having both; and the need occasionally to contradict what enrollees report being told by marketing staff

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