Case Managers: Embrace and Be Catalysts for Change

Catherine M. Mullahy, RN, BS, CRRN, CCM, FCM

There’s no question that health care in America is at a critical crossroad. The pandemic, coupled with persistent health care labor shortages and rising inflation, have had a major impact on health care providers (most notably those serving in hospitals) and patients. While providers grapple with maintaining financial stability as the costs of care continue to rise, case managers in various settings are playing a vital role in providing patient care in the context of today’s value-based health care system. The challenges case managers face day-today as they care for their patients and perform more and more administrative, data entry, and documentation tasks, demand that they gain the support they need from providers. Achieving cost-conscious care requires greater insight and action on the part of both health care providers and case managers. Case managers will need to take a more proactive and an openminded approach to new, transformational strategies.

Hospitals are facing unprecedented workforce shortages along with rising contract labor, medical supply, and drug costs. This is happening at a time when inflation is at historic levels. According to the health care consulting firm Syntellis Performance Solutions, between 2019 and 2022 hospital expenses rose 17.5%. In fact, more than 50% of America’s hospitals ended 2022 operating at a financial loss. One way hospitals can overcome some of their hurdles is with new government policies such as those that would help address their workforce challenges and prevent further Medicare or Medicaid payment cuts to hospitals. At the same time, the Centers for Medicare & Medicaid Services (CMS) must utilize its special exceptions authority to issue retrospective adjustments to address current market conditions.

For hospitals, other health care providers, and health care professionals—including case managers—transformation of strategies, policies, and programs is needed. All of these stakeholders want to ensure that patients receive high-quality, cost-effective care both conveniently and consistently; therefore, a team approach to solutions is imperative. To their credit and despite financial challenges, leading health systems are investing heavily in infrastructure to improve the coordination of care within the hospital environment and within other patient care settings. Case managers have always been at the center of patient care and relied on to coordinate, communicate, and share patient updates while also offering insights that can improve care and processes. But, case managers also have needs that must be met so they can ensure the best patient outcomes.

The role of case managers has continued to expand. In addition to assessing data relating to a patient’s hospital stays, they now are required to interface with the providers involved in their patients’ pre- and post-hospital care. Their transition of care plans must be comprehensive and address many goals, from reducing hospital readmissions and improving discharge processes, to ensuring that patients understand their medical condition and treatment plans, and reducing high-cost emergency department visits. On top of this, case managers have significant responsibilities in population health management and tracking of social determinants of health. They must also master myriad new technologies (eg, electronic health records, advanced telehealth platforms, artificial intelligence [AI]-driven software) along with utilization management, discharge planning, and care coordination. Today’s case managers must be able to navigate complex and siloed health care systems. It is clearly a challenging role that requires flexibility and open-mindedness to embrace new ways of doing things without compromising their ethics, professional standing, best practices, and, most importantly, their commitment to providing the highest standards of patient