Care Management for Chronic Diseases and Complex Healthcare Needs

Definition and Core Components

The American Geriatrics Society defines care management as a process of needs identification and service coordination designed to maximize function and independence while recognizing an individual's right to self-determination, essential for people with chronic diseases and complex healthcare needs 1, 2
Care management involves a structured approach to coordinating healthcare services across multiple providers and settings, including screening and case finding to identify individuals who would benefit from care management 2
Comprehensive assessment of patient needs across medical, psychological, functional, and social domains is a fundamental component of care management 2
Care plan development that addresses identified needs is a critical element of care management 2
Implementation of the care plan through coordinated service delivery and ongoing monitoring and adjustment of the care plan as patient needs change are essential components of care management 2

Care management is ideally provided by a multidisciplinary team including physicians, nurses, and/or social workers, according to the American Geriatrics Society 3
The care management team must be linked to the patient's primary or continuing medical care 3
While one qualified health professional may perform care management functions, the process involves coordinating multiple providers across all care settings 2

Patients and/or surrogates must actively participate in formulating the individual care plan, as recommended by the American Geriatrics Society 2
Patient empowerment in determining services is essential to the care management process 2
When services are denied or restricted, patients must be promptly informed and given the right to appeal 2

Effective care management addresses the medical, psychological, functional, and social domains of health care, according to the American Geriatrics Society 2
It coordinates health and social services with family-provided care 2
Care management helps control unnecessary utilization and costs while ensuring quality of care 2

Care management has been shown to increase services and reduce unmet needs for patients, as demonstrated by research published in the Journal of the American Geriatrics Society 2
Care management can increase patient confidence in receipt of care 2
Care management can improve life satisfaction 2

When the care manager is also a service provider, there may be conflicts of interest, as noted by the American Geriatrics Society 2
Services might be provided based on agency profit rather than patient need 2
Conversely, services might be inappropriately restricted if the manager is at risk for the cost of care 2

Funding for care management services is neither uniform nor fair, according to the American Geriatrics Society 2
Multiple reimbursement mechanisms create a confusing array of service providers and eligibility requirements 2

Care management teams serve as critical coordinators in the complex healthcare system, managing the confusing array of service providers, reimbursement mechanisms, and eligibility requirements that patients face 4
The American Geriatrics Society recommends that care management teams manage prior authorizations for medical services as part of their essential role in coordinating healthcare delivery for patients with complex needs 4

Prior authorization management is ideally handled by a multidisciplinary team including physicians, nurses, and/or social workers 4

Services might be inappropriately provided based on agency profit rather than patient need, or conversely, inappropriately restricted if the manager is at risk for the cost of care 4

Patients and/or surrogates must be actively involved in the care planning process, including being promptly informed when services are denied or restricted 4
Care management teams should have knowledge of relevant clinical areas, expertise, and an understanding of cultural diversity to effectively manage prior authorizations 4