Care management: it's in the eye of the beholder.

Care management isn't what it used to be. For one thing, it used to be called (and still is in many quarters) case management. It's just that some opt for the softer, more personal-sounding term "care." For another, it is not as focused on direct clinical services - diagnosis, prescription, procedure - as the traditional care management provided by physicians and nurses; today's term relates more to coordinating those services among various levels of care.

Also, just to set the record straight, care management is not managed care, but rather an important - some would say crucial - ingredient to making managed care work.

Care management is fairly well-defined in some areas of the health care system. In fact, there are at least two national organizations of care (or case) managers, who specialize in coordinating acute care medical/surgical services for hospitals, insurers or managed care organizations. When it comes to long-term care, though, definitions start to fuzz.

At the Alexian Brothers Health System, based in Elk Grove Village, IL, for example, care management ranges from the traditional clinical assessment and referral coordination to disconnecting stoves for the seriously cognitively impaired and modifying apartment doors to enhance ambulation. "Care managers" include not only geriatric nurse practitioners, but social workers, housekeepers and dining room hostesses. It all comes together around one unifying theme: keep elderly residents healthy and free of the need for expensive health care services.

"Our world doesn't revolve around hospitals and nursing homes anymore; our world revolves around physicians' offices and community-based programs," says Dan Gray, Vice President of Elderly Services for Alexian Brothers. The goal, he says, is to promote healthy behaviors and environments, i.e., prevention. And it seems to be working - despite an average resident age of 81 years, health care utilization at Alexian's residential facilities is at 7% a year.

Gray has seen care management evolving in stages. "CCRCs have been care managing clients forever. Housekeepers are trained as front-line 'social workers' to observe and report on changes in residents' health. Our CCRCs each have a resident life team headed by a social worker and including nurses, housekeepers, and hostesses from the dining area, who make their own observations. They meet once a month and plan interventions of all kinds, as needed."

More recently, an acute care component has been added with the advent, ten months ago, of a managed Medicare program. Here geriatric nurse practitioners and primary care physicians become more involved in the care management process. Gray says that a key concern is that residents can transfer from one Medicare HMO to another at will, with as little as 30 days notice. "You've made an investment in that resident's care. A loss of that resident is a boon to your competitors and a loss to your bottom line." Alexian Brothers Health system has learned, however, that residents are much less likely to switch if they have formed a bond with their primary care physician.

Enter, care management. "It involves an immediate health assessment by a nurse practitioner and scheduling of a physician's appointment within the first two weeks, instead of the first two months." This begins to encourage that bond and gets the preventive wheels rolling, Gray notes. Physicians are encouraged to be preventive-minded (if they needed to be) by the fixed-rate capitation payment they receive from Medicare. "In any event," says Gray, "you need that solid primary care base to make this work."

With one managed Medicare program covering about 2,500 residents, plans are afoot to extend its care management to chronic care services - a different challenge. "I, frankly, haven't a clue as to what this will entail in the care management workload. We're costing this at 100 to 200 cases per care manager (Alexian has four GNPs formally designated as such), but coordinating acute and chronic care is new, and no one really knows."

The PACE model experiments in this being conducted around the nation report hospitalization of only 6% of nursing home-eligibles, Gray notes. A further goal is to reduce nursing home admissions. "Our focus is to have nursing homes for those who need them, but to have fewer and fewer who need them. We need a much broader reach of nursing home-eligibles in our market to make this work. It's not the nursing home anymore, the community-based geriatric health center is where care management has to be focused these days."

Moving in that direction, but still primarily focused on the physician's office, the hospital and the nursing home, is the care management approach being developed by the St. Louis-based Deaconess Health System. In fact, care management as practiced by its three hospitals and two medical groups verges into what is more commonly referred to as utilization review - monitoring patients' stays in the hospital and the subacute unit, formally reviewing cases at fixed cut-off points and, if indicated, referring patients to a different level of care, whether skilled care, home health care or simply home. But, says James Sebben, PhD, Director of Geriatric Programs, the care management concept is still growing and developing.

"This is a real opportunity for long-term care providers to develop something that third-party insurers will buy off on, partly because they might not know how to do it themselves. We can offer assistance to insurers for when they start designing benefits for long-term care."

The key ingredient to getting this started, says Sebben, is the physician - specifically, the physician who can grasp conceptually what one is trying to do with care management, i.e., to coordinate services, understand reimbursement requirements and ensure quality of care at all levels. Also necessary are nurses; preferably with experience in various levels of care, who can provide day-to-day observations and recommendations about moving patients along the continuum.

Also, says Sebben, health system management must itself take a very activist stance good care in "selling" management and the necessary services to support it to physicians, HMOs and insurers. "If you set up a program solely to comply with what you think insurers want, you're going in the wrong direction," he says. "You're always reacting and not designing plans of care that will really work."

Sebben notes that local HMOs have been very cooperative in encouraging physicians to take a care management approach to managed Medicare patients in the Deaconess system. For example, physicians receiving the Medicare capitation may sub-capitate with other physicians who actually make long-term care visits in the nursing homes. "Not all physicians want to do this, in which case the sub-capitated physician becomes the primary," he notes. "Or they have the option of being the primary themselves, if they so wish."

It is this sort of flexibility, he says, that is required in managing typical long-term care patients and residents. The same applies to the use of practice guidelines, a managed care favorite for keeping physicians within affordable parameters. "Critical pathways have been suggested as a means of accomplishing this, but with the older population you can't be too rigid. They tend to have extreme diversity and complexity of health conditions that you don't tend to find with younger patients, and providers need the ability to make specific judgments as cases arise and conditions change."

The governing factor, making sure that these judgments don't fly off in needlessly expensive directions, is care management, says Sebben. "Good health care is, and always has been, efficient. Care management is a way of achieving this." Sebben cautions, however, that the care manager should not be viewed as a one-person operation. "This really must be a group effort, with each caregiver having a role."

Dan Gray, meanwhile, offers his own caution: "Care management is not a 'feeder strategy.' It is not a means of making sure that your facility gets the referrals, and anyone who adopts this stance will not make it. They're just digging in rather than going with the flow, and they will drown because they're anchored to the river bed."

Fortunately, he says, not-for-profits enjoy by their nature a key advantage for staying afloat. "Yes, they may get killed on price, and they're going to have to undergo a major cost self-assessment and reengineering to make sure this doesn't happen. But they are already oriented to providing a continuum of care. They've done it for decades." Now, he says, it's just a matter of making sure that the continuum provides some continuity of care for people moving through its various levels.

That's where care management comes in.