Surviving High Level Case Management: Are You Ready?

I must first make mention that this post primarily involves the healthcare market in the United States. I can’t extrapolate to say that these ideas have expressed applicability, internationally. Nevertheless, I do hope these words bring you both value and encouragement for the future. And, by the way, the direction of this post may take you on a different adventure than what you’d expect from the title… enjoy!

Case management is the word of the day. Why? Because, it controls e-v-e-r-y-t-h-i-n-g. In the near future, whether it be HMO’s, PPO’s, ACO’s… every bit of healthcare is trending towards a 100% managed care model. Clinicians and administrators on the other side of the payer are increasingly taking financial control over what is considered “medically necessary”, “covered”, or “skilled”, and thus, paid for.

The word “outcomes” is mentioned, whispered, ruminated, contemplated, debated, pontificated… and ultimately, its functional expressions are decreasing costs – shortening lengths of stay, minimizing utilization, and controlling for adverse events.

And thus, what is sure to be seen is a powerful shift from happy-and-unhealthy healthcare beneficiaries towards becoming unhappy-and-healthy – at least, that’s the intent. (We shall see!)

Are you ready to survive high level case management??? Ready or not, it is coming for you!

If you’re thinking about the outcomes, think again. Outcomes will generally be the same everywhere. Outpatient will be a blend of telehealth & minimal office visits. Acute care hospitals will try to discharge to home with home health or SNF/LTAC’s ASAP. Short stay rehab will try to cap visits in the range of 12-15.5 days and it will be even more difficult to qualify for acute rehab (ARU). Do positive outcomes truly matter? How about satisfaction? Biomarkers for health? Meh… the ivory tower isn’t really that concerned with such things… why? MONEY.

The reality is that the case management will generally be the same across the board; payer sources will utilize informatics softwares to project what should be necessary and trend their “outcomes” accordingly. Larger firms have more financial muscle to swing exceptions (ie. to authorized longer episodes of care, additional DME items, be lenient for customer satisfaction, etc.) – however – the bottom line exists ever so boldly. If a profit isn’t made, then a firm cannot afford to pay clinicians to give care. If they cannot pay clinicians to give care, then no care will be given and patients will become neglected and/or under-served.

Since outcomes will basically become a wash, then what is this going to be all about? Customer satisfaction. Why? Because, more and more insurance carriers are shifting towards PPO’s & HDHP’s+HRA’s/HSA’s – people want the choice of where they are seen for their care. Patients are no longer satisfied with being victims of the situation; they are involved, their families are involved, their caregivers are involved, their pets are involved… even their plants are involved! These consumers are not even close to shy in telling you how they like their care, when they like it, where they like it, what they like about it… and certainly, what they do not like! If they aren’t happy, they will most definitely go somewhere else and to someone else for their care. It is with comprehensive likelihood that the flow of care and customers in this industry will be dependent on volume based contracts and the percent satisfaction within that volume to keep in business.

So, how do we keep them happy? What elements of the patient experience will keep these customer’s satisfied? Answer: Meeting expectations. So what’s the secret? SETTING EXPECTATIONS.

Truth be told, every person goes into a patient care experience with some form of expectation – these expectations range from a subservient, victim-of-care mentality to a full force consumer with rights AND their GMD (Google Medical Degree). This is where healthcare can learn much from service industries regarding the setting and fulfillment of service expectations.

I made mention to one very successful case in The Service Experience Value Statement. Additionally, I shared my thoughts on the Disney experience and the Disney SERVICE model in a classic post: Lessons From A Disney New Year, Part 1. And, if we look at another service giant, Ritz Carlton, they have their “Three Steps of Service”:

Three Steps Of Service

A warm and sincere greeting. Use the guest’s name.

Anticipation and fulfillment of each guest’s needs.

Fond farewell. Give a warm good-bye and use the guest’s name.


And with this, I’d like to highlight another healthcare industry success story in regards to customer satisfaction and the creating of extraordinary patient experiences: Sharp Healthcare. Sharp holds all levels of staff to the standards of their Five Steps to Achieving Satisfaction – aka. AIDET. Yet, what Sharp is doing correctly is that it goes beyond the setting and fulfilling of expectations – their goal is to exceed expectations. One of the cultural gems of this firm is the emotional connection to the human experience in which Sharp employees naturally engage their patients. With this, a yearly documentary is unveiled called the “Stories of the Sharp Experience.

One may raise question as how this affects productivity and profit margins. Fortunately for Sharp, they are a non-profit organization. Yet, that aside, the business strategy here is the capturing of increased market share versus the micromanagement of staff efficiency, losses, and cost containment. Is it working? Well, they have grown to over 16,000 strong, numerous hospitals and outpatient clinics, and is the largest private employer in San Diego, California. I’d say, they are doing okay 😉

Finally, I would like to close this post by sharing one specific Sharp Experience story; a story which highlights physical therapy and that special connection in the point of service which our profession is so uniquely positioned to give. It is, perhaps, here in these moments, that the profession of physical therapy can demonstrate unique value through the contribution and restoration to the livelihoods of others.

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High level case management is here. Their patients, your consumers — are longing to receive healthcare from worthy providers who know customer service. Providers to whom they prefer; providers who care; providers who shine out and make that exceptional difference. Are you ready?