Can a "return to basics" help address nursing burnout?

This post was originally published on January 8, 2016. Rereading it made me wonder if the unraveling of nursing practice is related to the increased burnout and mass exodus from the profession in the US.

I want to recognize that Social Workers also play a significant role in Case/Care/Population Health Management.?Please keep that in mind as you read through the post below.

This blog is in reply to a question posted by Victoria Ng in LinkedIn’s Population Health Management, Accountable Care Organizations, Healthcare Data Analytics, PCM/ACO group. Victoria’s problem is

“Why do some ACO’s choose to implement care management technology while others don't?”

(Victoria is a graduate student at Columbia University and an intern at a tech company that is currently building care management technology). We’ll tackle her other question “How do ACO’s go about choosing which specific solutions to adopt” at a later time.

In the past six months, I've delved into countless articles, blogs, and related materials, all posing similar questions:

• "What exactly is Population Health?"
• "What's the connection between Population Health and ACOs?"
• "How does one go about selecting a Population Health vendor?"
• "What sets Care Management apart from Case Management within the Population Health domain?"

Admittedly, these inquiries often leave me tangled in confusion myself. Yet, these concepts aren't entirely novel. Similar care models have quietly existed for decades, coinciding with my tenure as a nurse, spanning over two decades. So why then do they remain largely unrecognized?

This question has been top of mind the past few months so when I read Victoria’s question, I decided to help in the best way I know how. I'm going to tell a story drawing from the teachings ingrained in me during my academic pursuits at the University of Michigan School of Nursing in 1990, and later at UCSF's graduate program in Nursing Informatics in 1999. These foundational definitions have served as guiding principles throughout my professional journey, navigating the intricacies of workflow design, devising and evaluating Case Management RFPs, and ultimately developing technology solutions tailored for Case Management.

A Definition

According to the Case Management Society of America (CMSA), the authoritative professional body representing Care Managers since 1983, care management entails:

“a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.”

Doesn't this sound like the embryo of a population health paradigm?

So what happened?

The year is 1920. During this era, Case Managers were integral in providing care and effectively managing healthcare costs by coordinating public health services for "patients."?The 1920s witnessed a burgeoning need to manage chronic illness, particularly among individuals grappling with mental disorders. Subsequently, the nursing profession surged to prominence in the 1930s, with nurses becoming pivotal in rendering house calls to patients in need. By the conclusion of World War II, numerous nurses assumed the role of Case Managers, orchestrating the myriad rehabilitation services required by returning war veterans. This expansion of the Case Manager's purview extended to public and private schools, where nurses spearheaded preventive health screenings and wellness initiatives, all while assisting families with various day-to-day necessities, delving into the realm of Social Determinants of Health (SDoH). As the role grew, Care/Case Management swiftly evolved into a "specialist role" in nursing practice.

However, significant shifts began materializing in the mid-1980s, propelled by double-digit inflation that compelled health insurers to prioritize cost containment. Consequently, insurance companies initiated Case Management programs targeted at curtailing costs associated with catastrophic injuries and illnesses, thereby birthing the "disease" or "condition-specific" definition of Case Management. This marked the initial "narrowing" of the pivotal role played by Case Managers in fostering community health and well-being.

The second narrowing occurred amid the spiraling costs of inpatient hospital care and dwindling reimbursement rates during the 1990s. In response, hospitals swiftly established acute care-based Case Management Programs, fixating on reducing Length of Stay (LOS) through early discharge strategies as a cost containment measure. Such intense cost-cutting endeavors even led some nurses, for the first time in their careers, to report through the finance hierarchy rather than the nursing chain of command. In certain regions, it remains commonplace to encounter Case/Care Managers whose only nursing experience revolves around utilization reduction and cost containment.

By the late 1990s, the relentless pursuit of cost reduction and the concomitant narrowing of nurses' roles in enhancing quality and advocating for patients sparked significant discord between Care Management Organizations, particularly HMOs, and Care/Case Managers. The negative public perception surrounding HMOs and Case Management was so pervasive that the term "Care Management" may have emerged as an attempt by the nursing fraternity to distance themselves from the adverse repercussions of the Managed Care/HMO movement.

If you were to inquire whether an organization employs Care/Case Managers today, they might say no. However, ask about the presence of Discharge Planners or Utilization Review nurses, and the response would likely be yes. Since 1920, Case Management has undergone many transformations, leading to a loss of common understanding of the nurse's fundamental responsibilities: furnishing education, solace, and support to patients and their families; advocating for the patient's best interests; identifying and addressing SDoH; and enhancing overall care quality.

So, why does this matter? Vast parts of the country still stuck in fee-for-service models, and fail to see the value of Case/Care Managers. But as we move towards value-based healthcare, their importance is becoming clear. You won't succeed in value based care without the expertise of Care/Case Managers.

As we transition from transaction-based healthcare to value-based models, an increasing number of organizations will realize the indispensable contributions of Care/Case Managers.?Indeed, accountable care for populations necessitates the specialized coordination, facilitation, translation, advocacy, and quality assurance functions that are foundational pillars of the nursing profession. I'm eagerly awaiting a resurgence of Care/Case Management roles, returning to the comprehensive scope of services of the past. This "back to basics" transformation would benefit patients, decrease burnout, and improve job satisfaction among nurses.

The fragmented evolution of nursing roles and responsibilities may be driving the collective ignorance regarding the value of nursing; and that Population Health is a return to the basics of holistic care for a community. From the 1920s to the 2020s, everything old is new again.

If you found this information helpful, please consider sharing it with your network who stand to gain a deeper understanding of nursing's pivotal role in Value-Based Care.