The Secret Sauce of Healthcare Reform

There’s a lot going on with healthcare reform.  The thousands of pages that outline the Affordable Care Act are intimidating for any lay person and even some experts to understand.  Its aim though is relatively simple:  better patient care, improved population health, and lower costs.  But how do you really achieve that?

There are a number of exciting initiatives that are underway to reach this triple aim.  Yet, from my perspective, I would argue that the secret sauce of healthcare reform centers on case management.  Case management can be defined as the coordination of health services across different providers and locations to promote quality, cost-effective outcomes for patients.  At its heart is a case manager or care navigator.  (Not to be confused with “exchange navigators”; the Feds released a proposed rule last week that defined the eligibility of people who are tasked with providing guidance to people enrolling in the federal health insurance exchanges)

Care navigators can be nurses, social workers, or other certified staffers that serve as advocates for their patients and help them make informed medical decisions.  They assist with referrals of new patients, coordinate the planning and delivery of care, and help evaluate results and adjust care plans as required (the WSJ provides an example here).  They have access to patient medical records and treating physicians. In most cases, these navigators are at no costs to the patient.  They are considered key parts of other reform initiatives, like patient-centered medical homes and accountable care organizations.

Most health systems are quickly moving in the direction of case management and navigators, including my own WellStar Health System, in a big way.  In a recent survey, the number of case managers in primary care grew from 14% in 2011 to 58% in 2012.

It is clear that care navigators can have a real impact on a patient’s health.  It is easy for a patient to get lost in the web of treatment plans, internists and specialists, and clinic locations spread across a large geographic area.  Having an advocate on your side can make all the difference in the world for better health outcomes.

But it begs the question as to why health systems would make such a large investment in hiring skilled clinicians for patients who already cost a lot.  It is reported that 20-25% of patients 65 and older are re-admitted after 30 days (the most expensive place to get medical care).  The answer: it actually saves money. Researchers at Baylor Hospital System in Dallas found that intervention by a care navigator cut readmissions of elderly health failure patients by 48%.

A health system can get its biggest bang for its buck, both in terms of health outcomes and costs, by focusing on high-risk patients.  The consulting firm The Advisory Board reports that on a national level 1.4% of the patient population consumed 10.9% of total hospital days.  This high-risk group puts a tremendous burden on our system.  Pairing a dedicated care navigator with the highest-risk patient is therefore bound to produce big results. They’re there to guide patients to the right doctor at the right time.  They can help provide education and emotional support to people who would otherwise might wait until their medical condition is so bad that are forced to visit an emergency room.

There is no single bullet to fix our ailing healthcare system.  Yet, case management and care navigators are certainly one of the best recipes to get us there.

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