Accountable Care Will Expand the Need for Case Managers

Traditionally, case management has been a tool reserved for complex cases, usually hospitalized patients needing multi-disciplinary interventions. However, that scenario may change as accountable care organizations take center stage next year.

With their mandated goals of cost containment and improved outcomes, ACOs will likely find they need case managers to strategically manage services for all patients, even those in ambulatory care. It’s been said that case management, with its current emphasis on complicated cases, needs to evolve into care management, with a focus on wellness, prevention, and efficient care for entire populations of patients – both inside and outside the hospital. Tomorrow’s case managers will have to consider clinical, financial, and patient advocacy functions simultaneously, as they balance competing interests.

It comes as no surprise then, that the Bureau of Labor Statistics, in its 2010 Occupational Outlook Handbook, identifies case management as a field projected to grow faster than other job categories. For nurses looking to be more competitive within the evolving marketplace of professional nursing practice, case management can be an excellent career choice. This “marketability” in the case management field will depend upon obtaining the credentials, education, and on-the-job experience that tomorrow’s employers will be seeking – so it’s crucial to identify the knowledge and skills you will need, and begin planning strategically to achieve them.

Case management education and credentialing

The field of case management is seeing a new emphasis on professionalism. A study by the Commission for Case Manager Certification (CCMC) reports that more employers are requiring case managers to be certified, and more employers are offering additional compensation for certification. Often, it’s expected that a newly hired nursing case manager will become certified within three years of starting the job.

Requirements for case management certification include:

  • a nursing degree and current license
  • at least 12 months of qualifying job experience
  • a passing score on a credentialing exam

So how do you land that first case management job without any experience? Online nursing degrees like American Sentinel’s MSN with a case management specialization can make you attractive to employers, provide you with case management knowledge and skills, and give you the academic background you’ll need to pass the credentialing exam.

Jobs with payors as well as providers

It’s not only hospitals and group practices that will be employing case managers, but insurers as well. In a pilot program described in this case study, Aetna pioneered the practice of embedding case managers into large physician practices that had at least 1500 patients enrolled in Aetna’s Medicare Advantage plan.

The case managers worked side by side with clinical staff, helping to manage patients with multiple conditions and coaching patients with chronic disease like diabetes. The face-to-face interaction enhanced their ability to collaborate and develop trust with medical staff. Results were positive, and Aetna was able to control costs by avoiding unnecessary hospitalizations and complications related to chronic disease.

What’s ahead for case management professionals?

In a rapidly shifting landscape, nurse case managers will need to keep up with new care models like ACOs and should even take a leadership role in their development. In addition to clinical skills and case management concepts, they will have to be knowledgeable about reimbursement models like capitation and pay-for-performance as well as other financial matters.

In addition to being more visible within the organization, case managers are likely to become more accountable. In order to really deliver, they must know their employer’s specific clinical and financial goals and plan strategically to help the organization reach those goals – whether it’s increasing preventive screenings like colonoscopies or bringing down rates avoidable readmissions. As they become the central coordinator of multiple activities, case managers will have to be ready to assume authority.