Partners in health

Mary Wegman, 51, the nurse-owner of a small care-management firm, recently paid a house call to an older woman in her wooden shack nestled in the Smokey Mountains just outside Knoxville, Tenn. Eligible for both Medicare and Medicaid, the patient suffered from pulmonary fibrosis and congestive heart failure, which frequently landed her in the hospital.

During the patient's most recent hospitalization, the staff member overseeing her discharge learned that she had no central heat, couldn't afford her medications and had no transportation to get to doctor appointments.

Fearing she wasn't able to continue living on her own, the hospital staffer alerted the insurer overseeing the patient's Medicare Advantage Dual-eligible Special Needs Program, which in turn reached out to Wegman's Choices in Senior Care. The goal: avoiding the most expensive option for the state—placement in a nursing home.

The registered nurse and her team of helpers immediately went to work to wipe out the woes that threatened the elderly woman's independence. By contacting the state Office on Aging, they returned central heat to the shack, which had been warmed by kerosene heaters and posed a carbon monoxide and fire risk. They connected her with a fellow church member who could give her rides to doctor appointments. They also connected her to a pharmacy program and secured a grant to cover her prescription medications.

“We were able to keep her in her home, which was made safer, and she was able to function at a higher level for quite some time,” Wegman said.

Care managers such as Wegman represent one of the faster-growing occupations in healthcare. However, people qualified and willing to take on these complex jobs are in short supply. Sometimes called care coordinators or even health partners, the new occupation combines nursing, social work and disability counseling. They can even serve as home health aides.

Demand for people who can effectively coordinate care and perform these multiple tasks has skyrocketed in recent years as payers and providers turn to healthcare delivery models aimed at lowering costs by keeping people with serious chronic conditions out of hospitals and in their homes. The nation's estimated 450 to 600 accountable care organizations increasingly employ care coordinators.

Ohio-based hospital system Mercy Health conducted a pilot between 2011 and 2012 of the impact of adding care coordinators to its staff. They found the new employees helped reduce readmissions by 35% and emergency department visits by 37% over the one-year period.

The CMS has encouraged use of care coordinators through its Financial Alignment Initiative demonstration project, which seeks to integrate care for the nation's 9.1 million poor and either elderly or disabled people who are eligible for both Medicaid and Medicare—the dual-eligibles. They frequently suffer from multiple chronic conditions and represent some of the highest cost patients for publicly funded programs.

Half of dual-eligibles have three or more chronic conditions, and six in 10 have cognitive limitations. While most are older than 65, four in 10 are younger with permanent disabilities. Often, the healthcare and other support services duals receive are fragmented and uncoordinated because these patients fall through the cracks of the two public programs.

Dual-eligibles cost about $319.5 billion in 2011, about 35% of total spending by Medicare and Medicaid, according to the Kaiser Family Foundation. To help bring those costs down, eight states have signed a memorandum of understanding with the CMS to carry out integrated care-coordination plans. Another 14 have active proposals submitted to the agency awaiting approval.

As these programs take off, it will only increase demand for care-coordination specialists. They not only attend to a patient's medical needs, but also their social and community needs. They perform these roles by telephone, in person and sometimes both.

While the care-coordination teams often include people from different occupations, registered nurses account for more than 90% of care managers, according to the Commission for Case Manager Certification, a nationally accredited organization that certifies case managers.

As demand for care coordinators grows, insurance companies and providers employing care coordinators confront a limited pool of people with the education and credentials needed to perform the work. Another recruiting hurdle is ensuring a strong balance between work and personal life. Most care managers are older, in second careers and prefer a more consistent work routine.

“I do worry salaries will go sky-high and that there are not enough people in the pipeline ready to take this job on,” said Eve Gelb, senior vice president of healthcare services at SCAN Health Plan in California. Her company, which coordinates care for dual-eligibles in the Los Angeles, San Bernardino and Riverside areas through its Medicare Advantage plan, expects to face stiff competition for care managers from companies such as LA Care and Health Net, which were hired by the state to run its CMS care coordination demonstration program.

Ohio will also be launching a demonstration program to coordinate care for dual-eligibles next year.

“We have been challenged to recruit highly qualified, credentialed nurse care managers to fill these positions,” said Steven White, president and CEO of Buckeye Community Health Plan, which will be competing against Aetna and Molina Healthcare for workers when enrollment begins in early 2014.

Humana executives say they expect “a fierce fight for staff” in Illinois as the state's demonstration project for dual-eligibles begins enrollment in February. As a result, the company may cross state lines to recruit, said Bill Jensen, vice president of marketing and sales at iCare, a Wisconsin-based insurance plan co-owned by Humana.

To attract nurses to the occupation, some companies offer in-house training courses in care coordination. Companies that offer education and have a proven history of working with the target patient audience will have an edge in recruitment, executives at several plans said.

“Organizations with a proven track record that also offer on-the-job training are key to attracting nurses and other individuals with clinical backgrounds as they may not have worked in a managed-care setting before,” said Rohit Gupta, director of Medicare at Inland Empire Health Plan, a company that will be offering coverage under California's dual-eligible demonstration. “Any organization that helps bridge that gap will not only attract care managers, but will see them remain in the long run.”

Training is a major issue for the fast-growing profession. Even nurses with decades of experience need new skills to take on the multiple tasks required in care coordination. For instance, changing patient behavior can be crucial to lowering medical costs, said Grace Chambliss, who manages cases for MissionPoint Health Partners, an ACO owned by St. Thomas Health in Nashville, which serves dual-eligibles.

A nurse with more than 20 years' experience, she is now in a multiweek coaching course that's teaching her skills including motivational interviewing. It's a question-and-answer technique that encourages patients to adopt healthier lifestyles or lose weight.

“In my previous life, I would have been bossy and said quit eating fried foods and go walk,” Chambliss said. “Now I say, how about trying to walk more? Or is it possible to eat just one piece of fried chicken?”

Care-management training programs also include education about relevant state and federal policies that affect the targeted patients as well as briefings on local community services. The goal is to put care managers on a more solid footing. “Things are changing constantly. There are various regulations and you need people to be fully updated,” said Claudia Fine, chief of professional services for Humana's SeniorBridge division. “You want them to feel confident.”

Like most subprofessions in healthcare, care coordinators are stepping up their self-organization efforts aimed at credentialing and education. Registered nurses in the field last summer created the Registered Nurse Ambulatory Care Coordinator Association, which recently formed a partnership with Cincinnati's Xavier University to provide a certification program in population health management. “My personal dream is that we create a place where we can share best practices,” said Lisa Cobb, a cofounder of the association.

Yet companies are looking beyond a single-professional approach to ensure there is an appropriate balance of skills in multispecialty teams it usually deploys to coordinate care. AmeriHealth Caritas, a Medicaid managed-care company and Independence Blue Cross subsidiary, has its nurse care managers primarily focus on the medical needs of clients while community health workers focus on the social or community issues. A community health worker usually has a better grasp of the services available in the community.

While most nurses might be open to attempting social service work when they first become care managers, “after a while, they'd move on to something else,” said John Baackes, president of the Medicare division for AmeriHealth Caritas.

Another stumbling block driving the shortage has been health plans' inability to find bilingual nurses willing to become care managers. Earlier this fall, Texas hired Cigna-HealthSpring to expand its coverage in 34 rural counties starting next year under the state's Medicaid managed-care program known as Star+Plus.

“One of the biggest challenges we have is finding service coordinators who are bilingual,” said Benjy Green, executive director of Cigna-HealthSpring Medicaid in Texas. “The ability to speak Spanish is important in a state like Texas.”

Being able to speak the same language as a patient can mean the difference between life and death, said Cecelia Houston, a Spanish-speaking care manager at Humana Cares. She said patients sometimes feel uncomfortable talking about intimate health problems with care managers who don't speak their native language. The problem might be hard to fix because there aren't enough Spanish-speaking nurses available, she said.

Officials don't expect the shortage of care managers to end soon. Early evidence shows greater employment in the field is leading to lower healthcare costs.

Follow Virgil Dickson on Twitter: @MHVDickson