A. Case management in community care settings may include ambulatorybased/clinic-based care, health care centers (both federally and nonfederally qualified or privately operated), physician group practices, accountable care organizations, patient-centered medical homes, and hospital-based clinics.

B. Case management in the postacute settings or levels of care may include acute and subacute rehabilitation hospitals/facilities, skilled care and nursing homes, “aging in place” (Fig. 6-1), and long-term care.

C. Most of the frail elderly in the United States require at some point or another community and long-term care or rehabilitation services in acute or subacute care facilities. This is mostly due to deconditioning after an acute care hospitalization or injury.

D. Today’s older adults and elderly patients who seek health care services encounter a variety of providers and organizations, including primary care physicians (ambulatory- and clinic-based care), specialists, acute care hospitals, skilled nursing facilities (SNFs), nursing homes, rehabilitation facilities, and home health care.

E. Assessment for placement of the clients/patients in a specific level of care should:

F. Health insurance plans usually pay for “medically reasonable and necessary” care. However, each insurance company has its own rules and definitions of “medical necessity” and “skilled” versus “unskilled” services that play an integral role in deciding whether to reimburse for care or not.

G. The prospective payment system (PPS) has resulted in patients’ early discharge or transition from the acute care/hospital setting to another less complex or restrictive level of care. This has increased the need for follow-up care in settings such as the patient’s home, provider’s clinic, and patient-centered medical home but most commonly in the longterm care and rehabilitation settings.

H. As integrated care delivery systems have become more common, new approaches to care, especially for the elderly, disabled, or functionally impaired, have been created. A common approach is subacute care, which is a level of care that blends acute and long-term care skills and philosophies.

I. Recent changes in health care delivery systems (e.g., Patient Protection and Affordable Care Act of 2010 and value-based purchasing programs) have resulted in an increased demand for case management and the role of the case manager in settings beyond the acute care/hospital, that is, long-term care, rehabilitation, patient-centered medical homes (PCMHs), federally qualified health centers (FQHCs), or accountable care organizations (ACOs).

J. Care of the older adult, elderly, and pediatric or young adult patients with one or more chronic illnesses requires the services of interdisciplinary teams of health care professionals including geriatricians, nurses, social workers, dieticians, physical therapists,
occupational therapists, speech and language therapists, and pharmacists, but especially case managers.

K. To ensure effective care of the elderly and chronically ill, the interdisciplinary team must assess specific aspects of the patient situation, health condition, and plan of care (Box 6-1).

L. Care for the aged, chronically sick, and mentally ill has been affected by specific milestones in laws and regulations in the United States (Box 6-2).

M. This chapter does not discuss provision of care in the ambulatory- and clinic-based settings. This is addressed in Chapter 4. However, the role case management plays in the ambulatory care setting is similar to that in PCMHs, ACOs, and FQHCs.

A. Activities of daily living (ADLs)—Activities related to personal care include bathing or showering, dressing, getting in or out of bed or a chair, using the toilet, and eating. If a person has any difficulty performing an activity by himself or herself and without special equipment, or did not perform the activity at all because of health problems (physical, mental, or emotional), the person is categorized as having a limitation in that activity. The limitation may be temporary or chronic.

B. Aging in place—Process by which a person chooses to remain in his or her living environment (home) and to remain as independent as possible despite the physical or mental decline.

C. Assisted living—A type of living arrangement in which personal care services such as meals, housekeeping, transportation, and assistance with activities of daily living are available as needed to people who still live on their own in a residential facility. In most cases, the assisted living residents pay a regular monthly rent and an additional fee for the services they receive.

D. Comprehensive outpatient rehabilitation facility (CORF)—A facility that provides coordinated outpatient diagnostic, therapeutic, and restorative services, at a single fixed location, to outpatients for the rehabilitation of injured, disabled, or sick individuals.

E. Continuing care retirement community (CCRC)—A housing community that provides different levels of care based on what each resident needs over time. This is sometimes called life care and can range from independent living in an apartment, to assisted living, to full-time care in a nursing home. Residents move from one setting to another based on their needs but continue to live as part of the community. Care in CCRCs is usually expensive. Generally, CCRCs require a large payment before an individual moves in and then a certain monthly fee.

F. Custodial care—The provision of services that can be safely and reasonably given by individuals who are neither skilled nor licensed medical personnel. These may include personal care, such as help with activities of daily living (bathing, dressing, eating, getting in or out of a bed or chair, moving around, and toileting). It may also include care that most people do themselves, like administering eye drops. In most cases, Medicare does not pay for custodial care unless if it is provided in a skilled care setting and under a skilled plan of care.

G. Custodial care facility—A facility that provides room, board, and other personal assistance services, generally on a long-term basis, which does not include a medical component.

H. Elder abuse—The willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting pain or mental anguish or the willful depreciation by a caretaker of goods or services that is necessary to avoid physical harm, mental anguish, or mental illness.

I. Elder neglect—The failure to provide the goods or services that are necessary to avoid physical harm, mental anguish, or mental illness.

J. Independent living—A service delivery concept that encourages the maintenance of control over one’s life based on the choice of acceptable options that minimize reliance on others performing everyday activities.

K. Inpatient rehabilitation facility (IRF)—A freestanding rehabilitation hospital or rehabilitation unit(s) in an acute care hospital that provides intensive rehabilitation programs; patients who are admitted to such facilities must be able to tolerate 3 hours of intense rehabilitation services per day.

L. Instrumental activities of daily living (IADLs)—Activities related to independent living, including preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone. If a person has any difficulty performing an activity by himself or herself and without special equipment, or does not perform the activity at all because of health problems, the person is categorized as having a limitation in that activity. The limitation may be temporary or chronic.

M. Limitation of activity—Refers to a long-term reduction in a person’s capacity to perform the usual kind or amount of activities associated with his or her age group due to a chronic condition. This may include a limitation in activities of daily living, instrumental activities of daily living, play, school, work, difficulty in walking or remembering, or any other.

N. Long-term care—A variety of services that help people with health or personal needs and activities of daily living over a period of time. Longterm care can be provided at home, in the community, or in various types of facilities, including nursing homes and assisted living facilities. Most long-term care is custodial care, which few (if any) insurance companies will pay for if skilled care is also not required, with the exception of long-term care insurance.

O. Long-term care insurance—A private insurance policy to help pay for some long-term medical and nonmedical care. Some long-term care insurance policies offer tax benefits; these are called tax-qualified policies.

P. Multidimensional assessment or comprehensive geriatric assessment (CGA)—A comprehensive assessment that includes evaluation of an elderly patient in several domains: physical, mental, socioeconomic, functional, and environmental status.

Q. Noncovered services—These services are not considered skilled and do not meet the requirements of a Medicare benefit category, are statutorily excluded from coverage on grounds other than 1862(a)(1), or are not considered reasonable and necessary under 1862(a)(1).

R. Nursing home—A residence that provides individuals with a room and meals and assists with activities of daily living and recreation. Generally, nursing home residents have physical or mental problems that keep them from living on their own. They usually require daily assistance.

S. Occupational therapy (OT)—Structured activity focused on activities of daily living skills (feeding, dressing, bathing, grooming), arm flexibility and strengthening, neck control and posture, perceptual and cognitive skills, and using adaptive equipment to facilitate activities of daily living.

T. Outpatient care—Medical, behavioral, or surgical care that is provided in a clinic/ambulatory setting and does not include an overnight hospital stay.

U. Personal care services—Nonskilled assistance (e.g., bathing, dressing, light housework) provided to individuals in their homes.

V. Physical therapy (PT)—Structured activity focused on mobility skills (bed and chair transfers, wheelchair use, walking), leg flexibility and strengthening, trunk or gait control and balance, endurance training, and use of adaptive equipment to facilitate mobility and physical functioning.

W. Predictor of repeat admissions (PRA)—A valid and reliable tool for identifying high-risk seniors (age 65 years or greater) who have a statistically higher probability of repeat hospital admission; developed by Chad Boult and associates from the University of Minnesota.

X. Reasonable and necessary care—Health care or services that are required by Medicare recipients and that is considered important for their medical condition. The Medicare program generally covers only items or services that are “reasonable and necessary” for the diagnosis or treatment of illness or injury or “to improve the functioning of a malformed body member.” This “reasonable and necessary” language is the basis for most Medicare coverage policies, but its meaning remains ill defined and controversial.

Y. Rehabilitation—A restorative process through which an individual with a complex, chronic, or terminal illness develops and maintains self-sufficient functioning consistent with his/her capability. Usually provided by licensed health care professionals such as nurses and physical, occupational, and speech therapists.

Z. Respite care—Temporary or periodic care provided in a nursing home, assisted living residence, or other type of long-term care program so that the usual caregiver can rest or take some time off.

AA. Restorative nursing services (NRS)—Replication of activities initiated by a physical therapist (PT), occupational therapist (OT), or a speech-language pathologist (SLP) and then performed and maintained by the nursing staff. These may include services such as range-of-motion exercises, dressing, personal hygiene, walking, and feeding.

BB. Skilled care—The provision of services that can be given only by or under the supervision of skilled and licensed medical personnel/health care professionals, that is, skilled and competent staff such as registered nurses; social workers; physical, occupational, and speech therapists; rehabilitation counselors; and registered dietitians/nutritionists. These staff are required to manage, observe, and evaluate the skilled care activities.

CC. Skilled nursing care—A level of care that includes services that can only be performed safely and correctly by a licensed nurse (either a registered nurse or a licensed practical nurse).

DD. Skilled nursing facility (SNF)—A facility (which meets specific regulatory certification requirements) that primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital. Sometimes referred to as nursing facility.

EE. Skilled nursing facility care—A level of care that requires the daily involvement of skilled nursing or rehabilitation staff. Examples of skilled nursing facility care include intravenous injections, wound care,
and physical therapy. The need for custodial care (e.g., assistance with activities of daily living, like bathing and dressing) cannot, in itself, qualify for Medicare coverage in a skilled nursing facility.

FF. SNF coinsurance—For day 21 through 100 of extended care services in a benefit period, a daily amount for which the beneficiary is responsible, equal to one eighth of the inpatient hospital deductible.

GG. Speech and language pathology (SLP)—Structured activity focused on communication skills, perceptual and cognitive skills, and swallowing.

HH. Federal Qualified Health Center (FQHC)—Are outpatient clinics that qualify for specific reimbursement systems under Medicare and Medicaid. Original FQHCs from the early 1990s were grant-funded programs under Section 330 of the Public Health Services Act. They functioned as “safety net” providers such as community health centers, public housing centers, outpatient health programs funded by the Indian Health Service, and programs serving migrants and the homeless. The main purpose of the FQHC Program is to enhance the provision of primary care services in underserved urban and rural communities. FQHCs expanded as a result of the Patient Protection and Affordable Care Act of 2010 to also function as patient-centered medical homes.

II. FQHC Look-Alike (FQHC LA)—Are health centers that have been certified by the federal government as meeting all the Health Center Program requirements, but do not receive funding under the Health Center Program or Section 330 of the Public Health Services Act.

JJ. Community Health Center (CHC)—A general term not defined in Section 330 of the Public Health Services Act that is used to describe community-based clinics, ambulatory care provider practices, or care centers.

A. The Case Management Society of America (CMSA) describes in its standards of practice for case management that case management extends across all health care settings (CMSA, 2010). This includes community-based levels of care, long-term care, and rehabilitation, the focus of this chapter. For example:

B. Case managers, according to CMSA, are recognized as expert clinicians and vital participants in the case management and care coordination team. They empower people to understand and access quality, safe, cost-effective, and efficient health care services (CMSA, 2010). These characteristics of the case manager are especially important when dealing with vulnerable patients/clients such as the elderly and older adult at a time of most need such as when suffering multiple complex illnesses or requiring placement in a long-term care facility.

C. Delivering patient-centered care and services is one of the goals CMSA describes in its standards of practice. This is especially synergistic with the demands imposed on the health care delivery system by the Patient
Protection and Affordable Care Act of 2010, which resulted in the proliferation of care settings such as the patient-centered medical home and accountable care organizations, known to improve primary care and advance the roles case managers play today.

D. The various roles and responsibilities case managers assume in the diverse health care settings described by CMSA in its standards for case management (CMSA, 2010) are all important and apply to the roles of case managers in the community and long-term care settings. However, of special importance are the following when case managers care for the elderly and older adult patient who is often vulnerable and at risk of receiving suboptimal care and services.

A. Federally Qualified Health Centers (FQHCs) have existed for more than 25 years. They are community-based health care providers that receive funds from the Health Resources and Services Administration (HRSA) Health Center Program to provide primary care services in underserved and rural areas (USDHHS, 2013).

B. The original defining legislation for Federally Qualified Health Centers is Section 1905(l)(2)(B) of the Social Security Act. FQHCs’ benefit under Medicare became effective in October, 1991, when Section 1861(aa) of
the Social Security Act was amended by Section 4161 of the Omnibus Budget Reconciliation Act of 1990 (USDHHS, 2013).

C. In June 2011, the Department of Health and Human Services announced the FQHC Advanced Primary Care Practice (FQHC-APCP) demonstration project as part of the PPACA and under the authority of Section 1115A of the Social Security Act, and upon the establishment of the Center for Medicare and Medicaid Innovation (CMI).

D. Reimbursement for care provided by FQHCs changed to the prospective payment system (PPS) method in October 2014, under Medicare Part B. Prior to PPS, Medicare paid FQHCs directly based on an all-inclusive per visit payment.

E. The quality of the care provided in FQHCs equals and often surpasses that provided by other primary care providers or settings.

F. FQHCs play an essential role in the implementation of the PPACA. They use quality improvement practices, health information technology (e.g., electronic health records, digital tools), patient-centered and culturally appropriate care, and case management services to ensure better quality, desirable outcomes, and safer care.

G. FQHCs’ model of care overcomes geographic, cultural, linguistic, and other barriers by employing a team-based approach to care. The team consists of physicians, other advanced providers (e.g., nurse practitioners, physician assistants, certified nurse midwives), case managers, clinical nurses, dental providers, social workers, behavioral health care providers, health educators, community health workers, pharmacists, and many others.

A. The Agency for Healthcare Research and Quality (AHRQ) recognizes that revitalizing the primary care delivery system is foundational to achieving high-quality, accessible, efficient health care for all Americans. It also believes that the primary care medical home is a promising model for transforming the organization and delivery of primary care (AHRQ, 2015).

B. The primary care medical home is also known as the patient-centered medical home (PCMH), advanced primary care, the health care home,
or patient-centered health home. Regardless of the terminology used, it refers to a primary care transformational model that exists in a community-based clinic, physician group, or physician-hospital practice. It provides ambulatory care services with special focus on the provision of holistic care by a primary care clinician (a doctor of medicine or doctor of osteopathy or advanced practice registered nurse or physician assistant).

C. AHRQ defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care. The medical home encompasses five functions and attributes (Box 6-4).

D. The PCMH is accountable for meeting each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.

E. The PCMH provides primary health care that is patient centered and relationship based with an orientation toward the whole person.

F. The patient-centered medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports.

G. The patient-centered medical home delivers accessible services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone, or electronic access to a member of the care team.

H. The PCMH demonstrates a commitment to quality and safety including quality improvement.

I. Currently, most PCMHs have moved in the direction of focusing on population health. In this regard, they identify the common chronic illnesses prevalent in their market share and the community they serve, assess and monitor the quality of care measures (e.g., hemoglobin A1C for diabetes) appropriate for each of the chronic illnesses, and implement improvement plans in these measures to ultimately enhance the quality and safety of the patients and the health of the population.

A. Accountable Care Organizations (ACOs) are groups of physicians, hospitals, and other health care providers, who come together voluntarily to provide coordinated and high-quality care to Medicare beneficiaries. ACOs resulted from the enactment of the Patient Protection and Affordable Care Act in 2010, under the CMS Center for Innovation (CMS, 2015b).

B. Medicare offers three types of ACO programs. They are according to CMS as follows:

C. Fee-for-service Medicare patients who see providers who are participating in Medicare ACOs maintain all their Medicare rights, including the right to choose any doctors and providers who accept Medicare. Whether a provider chooses to participate in an ACO or not, their patients with Medicare may continue to see them.

D. The Pioneer ACO Model allowed the experienced provider group participants to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with, but separate from, the Medicare Shared Services Program (CMS, 2015b).

E. CMS is moving to a Next Generation ACO Model, which applies refined benchmarking methods that reward the attainment and improvement in cost containment. In this model, it transitions away from comparisons to an ACO’s historical expenditures.

A. Case managers are integral members of the health care teams responsible for provision of care in FQHCs, PCMHs, and ACOs. The role of the case manager is similar in these care settings (Box 6-8).

B. Case managers assume the role of care coordination and management for a caseload of patients cared for in the FQHC, PCMH, or ACO. They complete a comprehensive assessment of each individual they care for to identify their health and social support needs. They periodically reassess the patient and update available information, including when new medical problems or other changes in health or functional status arise. The assessment may include the following:

C. Assessment of patient for health risk stratification using predictive modeling methods and techniques is common in the FQHCs, PCMHs, and ACOs. Case managers play an essential role in the assessment and classification or stratification of patients into a risk category: low, moderate, high, or very high.