Case Management

A basic flaw in the community-based long-term care demonstration projects was absence of health care services. Case managers could only develop care plans and coordinate covered community-based and in-home services. Clearly this approach does not adequately address the health care needs of older adults, who are major utilizers of health care services. In order to effectively address this reality, it was necessary to develop delivery systems that integrate services across the continuum of care, with particular attention to involving primary care physicians.

The Program of All-inclusive Care of the Elderly (PACE) and the Social Health Care Maintenance Organization (S/HMO) were developed to completely integrate services and financing for both acute- and long-term care services. Both programs incorporate a capitated payment for each participant, blending Medicare and Medicaid funds. In capitated programs, providers agree to provide a comprehensive package of services for a predetermined cost. This funding method introduces strong incentives for providers to establish cost containment mechanisms and to carefully monitor participant service utilization patterns. Case managers play a key role in these settings where providers have assumed financial risk.

PACE is based on the ON LOK program, which has been in existence in San Francisco since 1971 (Ansak). It is built on the adult day care model, and participants regularly attend a center where they receive primary care, and nursing, recreational, personal care, day health, preventive, rehabilitative, and social services. Case management in PACE involves an interdisciplinary team located on-site. Contracted services, which include hospital, nursing home, and specialist care, are also managed by the team. A team capable of effectively and efficiently managing the complex and changing needs of a frail population is composed of members who are strong in their specific disciplines, and have skills and attitudes that facilitate collaboration. Case management, as practiced by PACE teams, is focused on providing integrated health and social services within specific fiscal limits. The PACE model has been disseminated widely and has been implemented in diverse settings (Chin Hansen). The Balanced Budget Act of 1997 made PACE a permanent provider under Medicare and a state option under Medicaid, and authorized further expansion of the program.

The Social Health Maintenance Organization (S/HMO), which was launched in 1985, enrolls a cross section of Medicare-eligible persons. The program receives a capitated Medicare and Medicaid blended payment for each enrollee and assumes financial risk. All enrollees receive Medicare benefits. Frail clients also receive a limited long-term care supplement that is controlled by a case management unit composed of nurses and social workers.

Case management has been prominent in every S/HMO site. Case managers assess chronic care needs, authorize services for enrollees, and assist enrollees in obtaining noncovered services and benefits. S/HMO case managers coordinate service delivery and are responsible for facilitating continuity of care across the delivery system at key transition points, including hospital admission, hospital discharge, starting home care services, and nursing home placement.

S/HMO experience provided significant insights regarding physician involvement and highlighted the need to create policies and processes to enhance physician involvement in postacute care. In the original sites, primary care physicians were not consistently involved with their patients who were receiving long-term care benefits. (Leutz; Finch et al.). In addition, the S/HMO focused attention on the need to streamline assessment and more closely coordinate Medicare skilled care with community care benefits. S/HMO programs have demonstrated that enrollees benefit from efforts of case managers to maximize their care options.