Provider systems using care coordinators are reassigning responsibilities to optimize the use of their clinical professionals. Insurers also have expanded their use of care coordination, particularly in Medicare and Medicaid managed-care plans. That has freed doctors, advanced practice nurses and physician assistants to focus on their clinical duties. Meanwhile, nurses, social workers and case managers have been pressed into service as coordinators to help the most complex patients. Medical assistants and others with less clinical training and expertise visit patients at home with online support from doctors and nurses. Some care-coordination efforts train medical assistants or community health workers to collect more patient information or coach patients in behavior change.
With the new division of labor comes the need to build trust among the team of providers and delegate responsibilities without creating new gaps in communication or stoking anxiety among doctors and nurses about sharing responsibility for patient care. “One of the issues is making sure (you're) not involving so many people and collecting so much information that you're actually complicating the continuity of care,” said Dr. Eugene Rich, a Mathematica senior fellow who studies care coordination.
There also are financial challenges for providers in covering the additional costs of these care-management services, including hiring new care coordinators. That's because many insurers that still rely on traditional fee-for-service payment don't necessarily reimburse for nonmedical care-management services.
In addition, providers and insurers face a limited pool of people with the education and credentials to coordinate care. Many organizations are experiencing stiff competition for qualified, credentialed case managers and are launching training programs because even experienced nurses need new skills to handle the multiple tasks in care coordination.
Patrice Sminkey, CEO of the Commission for Case Manager Certification, based in Mount Laurel, N.J., said there has been burgeoning demand, with the number of actively employed certified case managers growing from 20,000 five years ago to 37,000 now. About 89% are registered nurses, about 5% are social workers, and the rest are people with counseling or other backgrounds.
There is a particular shortage of case managers who speak Spanish and other languages besides English, some providers and plans say. Median annual salary for certified case managers in non-management positions last year was $70,000 to $75,000, according to the commission. Sminkey said she is seeing more openness from doctors and other clinical professionals to the use of case managers.
The growing shift to value-based payment and patient-centered medical homes has driven the use of case coordinators by creating financial incentives for meeting quality and cost targets. Accountable care and capitated payment models give providers greater flexibility to use resources for care management, since global payments can be used to pay for the nonclinical services that care coordinators provide.
Federal labor projections show above-average growth for occupational categories that are among those recruited for care-coordinator jobs. Jobs for nurse practitioners are expected to increase 31% during the decade that ends in 2022. The projected growth rate for medical assistants is 29%, and it's 21% for the combined category of health educators and community health workers, who are often trained on the job.
Healthcare providers are more frequently including social workers on primary-care teams as part of efforts to address socio-economic and social service issues facing patients, said Christina Winans, senior director of performance technologies at the Advisory Board Co. Demand for social workers is projected to increase 19% through 2022.
As insurers and health systems negotiate more value-based contracts, the need for care-coordination staff will only increase, said Dr. Molly Joel Coye, chief innovation officer for the UCLA Health System. “There is growing interest in coordinating care in order to prevent more expensive downstream utilization, including emergency rooms and hospitals,” she said.
Patients discharged from the hospital are one of two major groups being targeted for care coordination, said Dr. Simon Samaha, principal with PriceWaterhouseCoopers. Providers are deploying nurses to coordinate these patients' post-acute care to prevent repeat visits to the hospital, he said.
The other major target group is patients at high risk of being hospitalized. The latter group of patients, who often are in Medicare or Medicaid, frequently need more than medical services to maintain their health and well-being, such as assistance with transportation and housing issues. “You have to go into the patient's home,” Samaha said.
Under its care-coordination program, Crystal Run Healthcare, a large multispecialty medical group in Middletown, N.Y., sends advanced practice nurses into the community to visit high-risk patients at home. Hospital readmissions within 30 days have dropped as a result, said Dr. Gregory Spencer, Crystal Run's chief medical officer.
His organization has a risk contract as a Medicare ACO. In the absence of such contracts, however, financing for care coordination is limited. “You're doing this work and the payer is benefiting unless you have a risk piece to the contract,” Spencer said.
The Advisory Board's Winans said sophisticated provider systems use data to help care coordinators identify patients at greatest need of intensive support. That reduces the workload for primary-care physicians.
Care-coordination programs may require nurses and other professionals to step into new roles or work more closely with staffers in newly created jobs. That often happens in a team, where clear delegation of responsibilities is essential.
The UCLA care-coordination program provides medical assistants and other staffers, including people without any clinical background, with two months of training in care coordination.
Coye said her system placed the coordinators in the clinics to help patients with their primary care and disease-management needs. Placing coordinators in the clinic allowed doctors to work more closely with the coordinators, building staff trust in the initiative. “It did solve the physician confidence issue,” she said. And it was “surprisingly efficient and effective.”
Arnaout sits outside Chen's office. Patients contact her directly, and she can consult Chen when needed. Meanwhile, Chen relies on her care coordinator to communicate directly with patients, their family members and other caregivers, including medical specialists. This arrangement has changed Chen's workload and her relationship with her patients. “It's better coordination of care,” she said.
—Harris Meyer contributed to this article.
