Most value-based care conversations focus on how provider coordination can maximize care delivery. These discussions frequently overlook one important puzzle piece—the role patients play in their own healthcare.
However, vital as their participation is, some patients aren’t equipped to take this journey alone. In these cases, a patient advocate can help them navigate the complex healthcare system. This is the role of clinical case managers (CMs).
CMs are healthcare professionals who partner with patients, helping them secure the services they need to optimize their long-term health. Overall, they connect patients with resources that can address any obstacles to their comprehensive care.
According to Laura McIntyre-Long, BSN, RN, a clinical case manager with Innovista Health, CMs are frequently the only contact patients may have with healthcare personnel in their insurance group. CMs work with the medical groups’ interdisciplinary members (providers, clinical staff, utilization management, and referral coordinators) to advocate their needs as they are identified.
“We provide outpatient support to the members we determine are most in need,” she says. “We work with these patients to assess their gaps in care and determine why they aren’t adhering to their treatment plan. If there are unforeseen barriers, we help patients overcome them.”
Mitigating social determinants of health (SDOH) is a vital part of successful case management. But CMs regularly offer services far beyond that.
They review emergency department and referral reports to identify which patients need assistance, and they help with:
Overall, CMs ensure patients maximize their healthcare experience.
“We provide a lot of education around adherence to a patient’s treatment plan,” McIntyre-Long explains. “We walk them through their provider’s instructions and help them access resources. We’re always looking for the best network options so they can find services closer to home.”
CMs connect with patients as frequently as possible. Even a single monthly touchpoint can be enough to detect any changes in a patient’s condition and make alterations that could help them better adhere to their doctor’s guidance.
Research shows CM efforts help to minimize emergency department (ED) use and have a direct impact on reducing ED and inpatient hospitalization costs. Overall, emergency care costs can drop 26–45% for patients paired with a CM, and their inpatient charges can decrease by up to 67%.
CMs can also benefit their institutional partners. For example, McIntyre-Long created a diabetic durable medical equipment playbook for Innovista’s partnering providers. This came about when she determined that many patients with diabetes were filling their testing supplies at pharmacies instead of using the medical equipment benefits available through their insurance. Consequently, they were paying out-of-pocket for their daily supplies. At the same time, medical groups had been recording those testing strips and sensors as non-generic on their pharmaceutical scorecards.
McIntyre-Long seized the chance to help. She contacted several durable medical equipment providers to collect the correct billing codes for these supplies and compiled them into a playbook that Innovista now distributes to physicians.
“Now, providers can work with a durable medical equipment company instead of a pharmacy, so patients don’t have an out-of-pocket expense for their supplies,” she says. “Patients can get their supplies delivered to their house, and medical groups aren’t getting dinged for using non-generic supplies through the pharmacy. It’s a positive for everybody.”
Just as every patient is unique, so is every workday for a CM. But most days do follow the same rough schedule.
“We typically start our days by reviewing our inpatient and emergency department logs,” McIntyre-Long says. “Typically, we focus on the members already enrolled in cases.”
During these initial hours, she examines utilization management team referrals. She also analyzes complex patient cases to determine where the patient is in their care journey and when she should reach out next. Then, she turns her attention to members she hasn’t contacted, looking for individuals who need CM services. She estimates she connects with at least 20 existing and new patients every day.
“As a group, we schedule multiple outreaches and try to complete a minimum of one monthly bi-directional contact with all of our enrolled members—yet many members require much more frequent contacts,” she says. “And we’re responsible for maintaining documentation on all those connections.”
By the very nature of their job, CMs face frequent challenges when helping patients navigate their health and healthcare.
When patients don’t comply with medical guidance, identifying the root cause is frequently the most significant obstacle, McIntyre-Long says. Their medication could be too expensive, they may not have transportation to their doctor’s appointments, or they may have a mental health condition that makes adherence difficult. In these cases, CMs often collaborate to find a solution.
“As a case management group, we come together as a team, pooling our strengths to pinpoint our best options and identify the community resources available to help our patients get to where they need to be,” she says. “We examine transportation options, look into financial support programs, get our members involved in wellness and support groups, find caregiver support, and can even secure free home modifications for patients with disabilities.”
Often, educating patients about their condition is the answer. The more patients understand, the more likely they are to abide by their doctor’s recommendations. But finding a message that resonates or strikes the right tone can be a hurdle.
“I try to be positive when I talk with patients so they understand why it’s important to follow their medical plan,” she says. “I also paint the picture that we’re here to support and encourage them—to build them up and improve their health.”
Through her efforts, McIntyre-Long helped one older man overcome his difficulties with a new ileostomy bag. He lived alone and had multiple ED visits during his first few weeks with the abdominal appliance.
To help him avoid a potentially negative outcome, McIntyre-Long scheduled routine visits with a wound care nurse, secured home health services to check on him between appointments, and arranged for home delivery of the supplies he needed. Thanks to these efforts, the patient thrived and recently underwent a full ileostomy reversal.
As the health professional with the closest, most routine contact with patients, CMs embody the philosophy behind value-based care.
“Case managers are essential in value-based care, which focuses on making sure patients receive the pertinent services they need. We work to facilitate coordination and proper authorization of those services,” McIntyre-Long says. “We’re often the first ones to identify what that need is during our telephonic contacts, and we’re the ones who are assessing their social, physical, and behavioral changes in between their in-office appointments with providers.”
It’s often a CM who alerts a patient’s provider to any changes. This communication helps the doctor intervene to avoid a decline in the patient’s condition or prevent a costly hospitalization.
Ultimately, CMs are critical, necessary partners to help patients become engaged participants in their own healthcare and experience better outcomes.