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Care Management Position Statement
American Geriatrics Society (AGS)

BACKGROUND

As the number of older people with complex health care needs increases, the demand for coordinated health care, including medical care and personal services, is growing. Different types of health care delivery systems, and an array of community-based services such as home health care, home-delivered meals, respite care, and adult day care have become widely available. Matching this complex system to the complex needs of older adults and other people with multiple chronic health care needs requires a coordinated effort by a team of professionals across the entire continuum. Care management is a process of needs identification and service coordination designed to maximize function and independence while also recognizing an individual's right to self-determination. The fundamental components of care management are screening, case finding, assessment, care plan development, implementation and monitoring. Although the care management components may actually be done by one qualified health professional (nurse, social worker, physician, other), or a care management team, the process of care management involves coordinating the different types of health care provided by multiple providers in all care settings, including the home, clinic, hospital, and sub-acute or long-term care institution.

Effective care management is a dynamic process, allowing for change according to the individual's needs. It should assure appropriate use of health and social services, coordinate these with family-provided care, ensure quality of care, and help with controlling unnecessary utilization and cost. To effectively meet the needs of an individual the care manager/care management team must address the medical, psychological, functional and social domains of health care.

The funding aspects of care management are neither uniform nor fair for those in need of services. Funding for individual services under various reimbursement mechanisms including Medicare, Medicaid, and private insurance leads to a confusing array of service providers, reimbursement mechanisms, and eligibility requirements for the patient. In this environment, care management plays a crucial role. Federal, state and private funding sources must recognize and support the valuable role of care management teams to ensure appropriate allocation of resources, improved health care outcomes and patient/family satisfaction.

POSITIONS

1. Care management is an essential component of coordinated health care delivery for people with chronic diseases and complex health care needs.
   

   Rationale: Studies have demonstrated benefits of care management to people receiving home and community based care and to patients with certain complex medical problems. Benefits to patients include: increased services, reduced unmet needs, increased confidence in receipt of care, and increased life satisfaction.

2. Methods should be developed to monitor care management with respect to under- and overuse of services.
   

   Rationale: Many professionals and health care organizations are involved in care management, including physicians, nurses, social workers, insurance companies, home health care agencies, hospitals, and Managed Care Organizations. When the individual who serves as care manager is also the provider of services or is a member of an organization or agency that provides services, there is a potential conflict of interest. If the care manager/provider profits from service delivery, services may be provided based on agency profit rather than on patient need. Conversely, services may be inappropriately restricted or abbreviated if the manager/provider is at risk for the cost of care (e.g., an Managed Care Organization or national long-term care insurance provider). It is important that the patients and their families understand how a particular care management program is funded. Measures of quality assurance and utilization review by appropriate third parties would therefore help to assure that the patient's or client's welfare remains the primary concern. Public disclosure is a powerful incentive for managers and providers to act in the best interests of their patients.

3. Patients and/or surrogates have the right to be informed of options for care and must actively participate in the formulation of the individual care plan.
   

   Rationale: Patients and families are keenly aware of their individual needs. Empowerment of patients and surrogates in determining what services are offered and chosen is essential to the care management process. When a particular service is denied, terminated, or restricted, patients, families, and/or caregivers must be promptly informed and given the right to appeal.

4. Care management is ideally provided by a team, which includes a physician, nurse and/or social worker. Care management must be linked to the primary or continuing medical care of the patient.
   

   Rationale: A crucial function of care management is to link medical care to the broader health support and social services required by a patient with complex health needs. Often the physician or primary care provider will be a member of the care management team or the care manager, but this is not always the case. However, medical guidance must always be provided by the patient's primary care physician, nurse practitioner or physician assistant, and care management assessments and care plans must be available to the primary care provider. It is vitally important for physicians and other primary care providers to understand and participate in the care management process that determines eligibility for home and community based services.

5. It is critical that the care manager and/or members of the care management team have a knowledge of geriatrics, clinical expertise, and an understanding of cultural diversity.
   

   Rationale: The care manager/ care management team member is most typically a nurse or a social worker. Other professionals, including primary care providers, pharmacists and physical therapists may provide care management services. In all disciplines, care managers must have multidisciplinary insight into key medical, functional and social issues important to the care of patients with complex medical and social problems. They must have a solid working knowledge and clinical experience in geriatrics and gerontology, including geriatric syndromes, geriatric assessment, evidence-based management of common chronic diseases, basics of rehabilitation, and components of home and community based care. In addition, they should have training in cultural sensitivity. Regardless of their primary discipline, these professionals must also have a clear understanding of the goal of care management and its fundamental components.

6. Reimbursement for care management must be coordinated and offer reasonable alternatives for people of different income levels.
   

   Rationale: Funding for care management is often fragmented and inconsistent. Comprehensive programs may be available for those with Medicaid eligibility or alternatively, significant resources, but may not be available to those of average means. Often care management services are only available through insurance companies, home care agencies or managed care organizations where conflicts of interest are possible. Care management should be considered a reimbursable benefit by Medicare and other insurances so that patients and their families could have improved access to and choice of this important service.

7. Continued research is needed to develop, refine, and appropriately target care management.
   

   Rationale: Demonstration projects that have been conducted to date provide an encouraging basis for the recommendation of care management for community-based long-term care. Further study is needed, however, to refine and target the use of care management. Research and demonstration projects are needed on care management models that empower patients and families through better access to information and decision-making assistance. Because not all persons need or would benefit from care management, further research is needed to determine the specific types of problems and service needs that are most effectively served by care management. Care management is not helpful in communities where services are extremely limited. Therefore, research is also needed to determine what level of service must be available to accommodate care management.

Developed by the AGS Public Policy Committee and approved by the AGS Board of Directors in November 1989. Reviewed April 1993. Revised by the AGS Health Care Systems Committee, with special thanks to Dr. Caroline Blaum, and approved in May 2000 by the AGS Board of Directors Representative to the Health Care Systems Committee. AGS, The Empire State Building, 350 Fifth Avenue, Suite 801 New York, NY 10118.