Case Management Society of America

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Advancing the Roles of Case Managers in Quality Improvement

BY KATHLEEN MOREO, RN-BC, BSN, BHSA, CCM, CDMS

Quality improvement (QI) has been woven into the fabric of case management practice since the first CMSA Standards of Practice for Case Management were released in 1995. Since then, and through three revisions to the Standards of Practice, the consistent delivery of improved care quality has remained a core element of case management practice. With recent developments in U.S. health policies and value-based reimbursement models that mandate conducting QI initiatives, some healthcare teams and entire systems are just catching up with case management’s ongoing focus on quality. How can we best utilize our QI experiences in case management, drawing on our collaborative practice skills, to help healthcare teams effectively implement leading QI principles and methods to achieve national goals of quality-driven and value-based healthcare? In this article, I’d like to share a few suggestions and insights based on the many results of research-informed QI projects that my organization (PRIME Education) has published in the literature.

Providing Support in Advanced QI Competencies

Case managers are ideally positioned to educate members of healthcare teams about advanced QI principles and methods, as well as support team-based and system-based QI implementation initiatives. We are well-versed in key QI-focused methods such as reviewing patient charts for hard and soft outcomes, conducting root cause analyses to identify sources of suboptimal care quality, and collecting data to assess barriers and gaps in care coordination. In addition, QI methods including Plan-Do-Study-Act (PDSA), Six Sigma and Lean are pivotal to case management approaches to improving care quality. To support our colleagues on clinical healthcare teams in achieving QI goals, we have unique opportunities for sharing our wealth of QI knowledge and experience.

Often, team members and administrative personnel who are responsible for QI initiatives in our health sites or systems may not be aware of our expertise in QI. We owe it to our professional practice and to our patients to share our training and experiences in QI so that we can be better utilized and recognized for the leadership we can bring to the QI team. Thinking back to my earliest career days in a community hospital, I was involved in my hospital’s Professional Standards Review Organization (PSRO) committee. At the risk of really dating myself, I will share that this mid-1970s approach to monitoring Medicare and Medicaid service delivery may be one of the earliest examples of how nurse case managers were conducting systems-based medical review protocols designed to ensure appropriate utilization practices, while also improving the quality of care being delivered in the hospital.

Promoting Case Management Quality Measures

As case managers, we can have highly influential roles in identifying areas for improvement in healthcare, whether we are working in acute care, community settings, long-term care, managed care, specialty pharmacy, independent practice or several other practice settings impacted by case management. A fundamental example is in our role of patient monitoring. We support patients, families and clinical teams in identifying service delays or gaps in access to care, inappropriate levels of care delivery, risks of safety issues or adverse events and gaps in patient education and advocacy. These roles directly align with common types of national quality measures, which focus on clinical processes for ensuring patient safety and promoting effective treatment practices. However, a great need exists for promoting national quality measures that focus on essential case management roles. These roles include, but certainly are not limited to, care coordination, handoffs and transitions of care, medication reconciliation, shared decision-making with patients and caregivers and supporting effective and timely communication among members of interprofessional healthcare teams. Our continued input on refining existing quality measures in these areas, as well as in developing new quality measures that are directly in the purview of case management, would be greatly valued by our own organizations as well as by key national stakeholder groups, including the National Committee for Quality Assurance (NCQA), the Agency for Healthcare Research and Quality (AHRQ), The Joint Commission and the Centers for Medicaid & and Medicare Services (CMS).

A recently enacted CMS program for promoting quality improvement is the Merit-based Incentive Payment System (MIPS) under the Quality Payment Program. Established under the Medicare Access and CHIP Reauthorization Act (MACRA), MIPS involves measures of care quality for providers that include care coordination, interprofessional communication, shared decision-making and other aspects of healthcare that also reflect the day-to-day roles of case management. As providers struggle to meet the tenets of MIPS, they could greatly benefit from the knowledge and expertise of case managers. Imagine how difficult it must be for a primary care physician to implement care coordination processes in his/her practice related to patient referrals, and how to document care coordination. Case managers have an invaluable opportunity to advance the role and QI competencies of case management through training and mentoring of providers. By advancing methods for objectively measuring the quality of care coordination, shared decision making, interprofessional communication and other aspects of healthcare that are central to our work, we also make exceptional contributions to national QI initiatives.

Designing, Conducting, and Reporting QI Initiatives

For the case management community, a key endeavor for supporting our colleagues in achieving national goals for quality-driven healthcare is to take leading roles in designing, conducting and reporting QI initiatives. These endeavors offer valuable opportunities to apply quality measures that are central to case management practice, as well as to identify the most effective interventions for improving care quality based on these unique measures. Central to this goal is the need to educate the larger healthcare community about our innovative QI approaches, impactful results and lessons learned. This process involves preparing and submitting manuscripts for publication in peer-reviewed journals that exist outside our professional circles. For the most far-reaching impact, we should strive for publication in high-quality medical and QI journals, in addition to case management journals for informing our peers.

The future of case management holds great promise, with national policies and systems-based QI initiatives so closely aligned with the work we do every day. The challenge in front of us is to recognize and widely share the QI results we engender through our tenacious roles and responsibilities.    ■

Kathleen Moreo, RN-BC, BSN, BHSA, CCM, CDMS, is CEO of PRIME® Education, a 25-year education and research company advancing healthcare improvement. Moreo is a CMSA Past President (1999-2000) and a current member of the South Florida CMSA chapter (SFCMN). She is an editorial board member of Professional Case Management.

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