More specifically, who coordinates the proliferating number of health care helpers variously known as case managers, care managers, care coordinators, patient navigators or facilitators, health coaches or even — here’s a new one — “pathfinders”?
Rachel Schwartz, a licensed clinical social worker for close to 20 years, came face to face with this quandary earlier this month. Employed by a home care agency in Virginia, she visited a woman in her late 70s who had recently come home from the hospital.
The patient, who lives with her husband and daughter, has diabetes and dementia. Ms. Schwartz, during the scant one to three social work visits that Medicare will cover, planned to help her sign up for community services like Meals on Wheels.
“We’re trying to keep people at home and out of hospitals,” she said.
But the woman also had a care manager through her Medicare Advantage program, her daughter reported, handing over a business card. Not wanting to duplicate those efforts, Ms. Schwartz left the care manager a message, then later texted a former colleague who worked for the same program. Did she know this care manager? They should collaborate.
No, the colleague didn’t know her. She might not be a field case manager, she texted back; she might be a telephonic manager.
Telephonic? “I thought, ‘Gosh, I don’t even know what that is,’ ” Ms. Schwartz said.
It wasn’t her first encounter with this sometimes puzzling new approach to health care. Recently, intending to arrange home care through Veterans Affairs for an older veteran, Ms. Schwartz learned that his Medicare Advantage care manager had already helped him apply for Medicaid home care. A younger patient’s “mental health case worker” had already submitted paperwork for the same Medicaid program Ms. Schwartz was about to recommend.
“I’m struggling with, what is my role? How do I best help my patients?” she said. To truly coordinate, “I need to think of calling every possible person involved, but I don’t always know who these people are.” (The nearly duplicated applications on behalf of the veteran came to light only because he happened to mention the other care coordinator’s first name, and Ms. Schwartz recognized it and called her.)
The law of unintended consequences seems at work here.
For decades, critics have lamented the fragmented American health care system: Your cardiologist doesn’t know which medications your endocrinologist has prescribed. The hospitalists directing your care don’t know whether you will need transportation for follow-up visits after you are discharged. Meanwhile, no one has told your primary care doctor you’re in the hospital.
Now, the Affordable Care Act and other attempts to make health care more effective and efficient (and less expensive) have created incentives and penalties that should, in theory, encourage one hand to know what the other is doing.
Thus, you may have a care manager through Medicare Advantage; nationally, about 30 percent of Medicare beneficiaries have enrolled in such programs. Your primary care physician’s office may offer care coordination; Medicare now reimburses for such services.
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Continue reading the main story The Case Management Society of America, the country’s largest professional organization for case and care managers and coordinators, has about 30,000 members and participants, the executive director Cheri Lattimer said. A decade ago, it worked with perhaps a third that many.
Hospitals, accountable care organizations, Medicaid programs, home care agencies, senior centers and other community organizations have followed the care coordination trend. “It’s infused the entire health care system,” said Joe Baker, the president of the Medicare Rights Center in New York.
“This is definitely good for patients,” he added. “I don’t know anyone who’d rather sit around in an emergency room or be admitted to a hospital if that can be prevented.”
Checking in with patients to help them manage chronic illnesses, find the services they need, understand their drug regimens, order medical equipment and adopt healthier habits could improve their well-being and ward off intensive and costly medical interventions.
But at this early stage, people who work with consumers and caregivers say, the multiplying number of coordinators is also creating some difficulties.
Patients and family caregivers — who are always the de facto care coordinators — may feel bombarded, said Carol Levine, the director of the United Hospital Fund’s Families and Health Care Project.
“I hear a lot about people getting discharged from the hospital, and four or five people call the next week: ‘How’re you doing?’ ” she said. Families wonder, “’Who are all these people, and why are they bothering me?’” she said. Sometimes, overwhelmed patients simply stop answering the phone.
Nor is it clear which coordinators have expertise or authority.
Once primarily nurses and social workers, they can now be what Mr. Baker calls “care managers in name only. They may make a phone call, but they don’t really do much.” Some may remind you to make an appointment; others can make appointments for you, perhaps earlier ones than you could get yourself. They may not be qualified to answer questions about medications.
More fundamentally, as Ms. Schwartz discovered, they may not be talking to one another.
“It’s not so much that there are too many cooks in the kitchen, it’s that the cooks are not always communicating,” Mr. Baker said. “We need to set up more rigorous protocols or structures, so we don’t have this who’s-on-first problem.” Perhaps, he suggested, a “dominant care manager” should guide the team.
Several experts I spoke with described these issues as growing pains, the inevitable disorder that accompanies substantial change in a complex system. It will get better, they said. Being contacted by several people whose job is to help you navigate the health care system is a good problem to have.
But in the interim, families encountering these new faces and titles have to ask questions: What is each coordinator’s role? What can he or she actually do? How long will the manager/facilitator remain involved?
Continue reading the main story Write A Comment The United Hospital Fund has assembled a Family Caregiver’s Guide to Care Coordination; Among its recommendations is to keep a log — on paper, on a computer or phone, via a patient portal — of who has called when, what each coordinator is working on, who has spoken to whom.
It seems an additional burden on people trying to get well, and on their often overtaxed caregivers, but it may promote coordinated coordination.
“Everybody’s trying to help,” Ms. Lattimer said. “But is everyone doing it in the most efficient and effective way for the consumer and the family? Or are we just confusing the issue?”