Coordination of Care for Persons with Disabilities Enrolled in Medicaid Managed Care: A Conceptual Framework to Guide the Development of Measures. B. Care Coordination And Case Management Or Care Planning


The term care coordination is often used interchangeably with the terms case management and care planning. Indeed, in many cases "care coordination" came to be used instead of "case management" because the latter term had negative connotations to patients. As one older gentleman told us in a focus group: "I am not a case and I don't want to be managed."

Case management has been used for decades to deal with specific target populations, including those who in the past might have been taken care of in institutions where "all" their needs were met (except, in many cases, needs for autonomy, dignity and individual development). When populations were either "de-institutionalized" as in the case of the chronically mentally ill, or "at risk for institutionalization" as in the case of frail elders, case management was used as a central part of interventions designed to patch together services that could take the place of those present in "total institutions" (Itagliata 1982; Bachrach 1993).

Over time, a set of specific functions became associated with case management or care planning, as it is sometimes called. These classic functions include:

  • Assessing the full spectrum of client needs;
  • Developing a treatment plan to meet those needs and specifying who would provide which plan elements to the client;
  • Arranging for services in the plan to be provided (and in some cases paid for);
  • Following up to ensure that services were in fact delivered and having the desired consequences; and
  • Periodically re-assessing needs and adjusting treatment plans accordingly (Kane 1987, Schwartz 1982).

Note that there is no explicit use of the term "coordination" in this set of functions. If we use Thompson's three types of interdependence, it would appear that case management is primarily dealing with "pooled" and "sequential" interdependence, rather than the more difficult "reciprocal" interdependence. In practice, however, many case managers do address the problems that arise when those providing services to a client are in fact reciprocally independent but may not recognize that fact and/or may fail to make the required "mutual adjustments." It is not clear that case managers anticipate these interdependencies and create or support mechanisms to deal with them (Siegel 1996). In many cases, they may not have the resources, skills, or "clout" to do so. We would argue that care coordination, to be effective, must.

We and others have argued that case management is a response to a broken and fragmented system, and that it has seldom been used to support system-level changes, but rather has been used to help individual clients navigate the shoals of turbulent health care systems (Evashwick1996; Sofaer 1994). As we have already noted, given the fragmented nature of health care today, it is likely that care coordination, too, will be required to find individualized "fixes" for specific people, because they cannot wait for long-term changes to be defined and implemented. At the same time, it would appear wasteful to ignore the learning that can be achieved when the experiences of multiple clients with system-level problems are aggregated and analyzed to identify patterns as well as opportunities for improvements. We therefore include, among the processes and activities included in care coordination (see Section VI below), participating in the process of identifying persistent system problems that impede care for people with disabilities (Schwartz 1982).

While the case management functions we have described above are generally common, many other aspects of case management vary in consequential ways. These include:

  • The disciplinary base and level of education/training of the case manager (for example, case managers for the chronically mentally ill vary from paraprofessionals through nurses and social workers to psychiatrists);
  • Whether or not the case manager is also providing direct clinical or other services to the client;
  • How much control or influence the case manager has over resources needed to access or purchase services;
  • The caseload size and mix of the case manager;
  • Whether s/he works only on services provided within a single agency or actually manages services provided by multiple agencies; and
  • A related issue, the range of services (i.e., medical and social, medical only, social only) that are being "managed" (Itagliata 1982; Kanter 1989).

While there are many opinions expressed in the literature about the "correct" approach on each of these dimensions, there is little solid empirical evidence to identify an approach that will always be the "correct" one. For the most part, therefore, we will try to avoid being either "prescriptive" or "proscriptive" as we move toward the development of measures. However, given that Medicaid managed care depends on the effectiveness of its contracts with MCOs, it is essential that in this area as in many others, contract specifications must be clear in order for MCOs to be held accountable for their performance (Rosenbaum 1998). Contract specifications, and measures, must and will reflect priorities and value judgments as well as empirical evidence.

For example, the last "bullet" relates to an issue that is both important and remains unsettled: should our measures speak to the coordination only of those medical services that are specifically covered, for example, in state Medicaid agency contracts with MCOs? Or should they also speak to the coordination of related social and human services (Rudolph 1993)? This gets at the issue of "what care is being coordinated?".In our discussions with our TAG consensus could not be reached on this issue. Medicaid state agencies believed that this responsibility for this kind of cross-sectoral coordination could not be paid for, therefore could not be "required" in contracts, and therefore could not be incorporated into a performance measure. On the other hand, virtually all our stakeholder advisers and our TEP agreed that somehow this kind of coordination had to take place, if the care of people with disabilities was to be truly "coordinated."

Leutz (1999) makes a useful distinction in discussing the coordination of acute and long-term care services, which can be viewed as highly related to coordination of medical and related social and human services. He and colleagues distinguish between systems that attempt full integration (see our discussion of structural integration below), coordination, and linkage. We suggest here that Medicaid MCOs do need to be held explicitly accountable for coordinating covered services; but that they should also be held accountable for creating linkages with those providing other related services. One potential problem here is that, in some cases, behavioral health services have been explicitly "carved out" from Medicaid managed care programs (Regenstein 2000). Given the high incidence of people with serious cognitive impairments and chronic mental illnesses within the group of people with disabilities, this may be such a fundamental problem for care coordination that it requires special attention, not only by the MCO but by the state Medicaid agency itself.

Other authors (e.g., Rosenbach1999) note that in many cases, other systems are resistant to working with the health care system. Some believe that the state Medicaid agency needs to take responsibility for convening and encouraging more positive interactions with other relevant state agencies (e.g., education, housing, foster care, mental health, developmental disability, services for the aging) as part of a move to explicitly incorporate people with disabilities (in particular, the SSI disabled) into managed care, especially mandatory managed care.

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