Identifying individuals needing care management and those providing it in the United States is a first step to understanding how care management can positively impact health and financial outcomes for older adults. This article describes who is most frequently receiving care management services, and the professional backgrounds and credentials of those who provide this service. The settings in which care managers work and the variability in care approaches is also discussed. A call for action for the government, private sector, and higher education institutions is made to increase recruitment and retention of care managers.
modifiable risk, care manager credentials, care manager recruitment and retention
As described in earlier articles in this issue of Generations, care managers assess the needs of older adults and individuals with disabilities and create plans of care to link individuals to medical and social services that will support their health and well-being. Care managers monitor the quality of care and services received and often advocate for care receivers when questions are raised related to services, program eligibility, and payment. Care managers can be found in a multitude of settings including hospitals, primary care offices, social service agencies, and insurance companies. The number of care managers practicing in the United States appears to be on the rise, in particular in area agencies on aging (AAAs) as part of Medicaid Home and Community-based Services (HCBS) Waiver programs (Eiken et al., 2018).
Significant differences in care management protocols and approaches have challenged efforts to link positive outcomes to case management services, and to identify how many care managers practice in the United States. Depending upon the setting and the role individual care managers play, their actions may be driven by a set of clinical guidelines or by professional expertise and experience (Olaison, Torres, and Forssell, 2018). Care management may be provided through a standardized electronic decision-making tree or an informal set of handwritten notes based on perceived areas of need. There is significant variation in how care managers use data to drive decision-making (Billings et al., 2006).
Understanding who could benefit from which type of care management in which settings is critical as case management is time- and resource-intensive, and the health and well-being of many individuals depends upon it. Farrell and colleagues (2015) note three elements needed for successful care management: identifying populations with modifiable risks; aligning care management services to the needs of the populations; and identifying, preparing, and integrating appropriate personnel to deliver those services. This article describes the basic demographics of the care management population, (including who needs care management); where care managers work and their credentials; state and program care management guidelines; and what the future holds.
Who Needs Care Management?
Care management addresses modifiable risks of the “highest risk and highest need” populations through health and social service interventions and support. Reducing risks, such as rehospitalization or nursing home placement, through care management may save money and improve care effectiveness. Care management is often provided during care transitions such as from hospital to home and to prevent transitions such as from community-based care to institutional care (Anderson, Dabelko-Schoeny, and Fields, 2018).
Individuals with chronic conditions such as congestive heart failure, diabetes, and Chronic Obstructive Pulmonary Disease appear to be the best candidates for care management, in particular those of low socioeconomic status. Older adults who live in poverty experience higher levels of chronic illness, mental health challenges, and low levels of health literacy, putting them at higher risk of poor health and institutionalization (Judd and Moore, 2011).
Individuals living with dementia also seem to benefit from care management. Jennings et al. (2016) found that people with dementia who received care management from nurse practitioners affiliated with their primary care doctor experienced a higher quality of care assessment, screening, and counseling. Finally, individuals who live alone, without informal caregivers available to assist in care management, could benefit from care managers.
Care management not only provides support for care recipients, but also for their informal caregivers. In the United States, 41.8 million Americans (16.8 percent) are informal caregivers for adults older than age 50 (AARP and National Alliance for Caregiving, 2020). Many family caregivers report that finding, accessing, and coordinating services for care recipients is a source of stress. The 2020 AARP Family Caregiving Report documented an increase from 23 percent of caregivers in 2015 to 31 percent of caregivers in 2020 reporting difficulties with coordinating care. Some of the most successful, evidence-based dementia caregiver interventions include care management (Bass et al., 2013; Clark et al., 2004; Samus et al., 2014).
Where Do Care Managers Work?
Care managers work in multiple settings including primary care, AAAs, hospitals, insurance companies, and in private practice. One of the central debates in care management literature is where care managers should be located, what work they should be doing, and who has the skills to do that work successfully (Morano and Morano, 2006). Judd and Moore (2011) argue care managers should practice within AAAs, focusing on older adults of low socioeconomic status.
Available in all U.S. regions, AAAs are established through the Older American’s Act (OAA) and designated by states to address the needs of older persons and individuals with disabilities (Anderson et al., 2018). The largest group of care managers in the United States likely work in AAAs with older adults through the administration of Medicaid waiver programs, managed care contracts, OAA programming, and other services and supports.
Care managers working in AAAs are able to establish multiagency care plans and work independently from providers. Care approaches support client choice and shared decision-making. Care managers in insurance agencies, on the other hand, are limited to defined provider networks and often are provided incentives to contain costs. AAAs partner with healthcare providers such as hospitals, mental health agencies, and other stakeholders that support “livable” or age-friendly communities. These partnerships have yielded reductions in healthcare use and cost (Brewster et al., 2020).
However, others argue care managers should be based in primary care, as a randomized trial found that primary care–aligned care management reduced the risk of mortality and permanent residential placement (Parsons et. al., 2012). These care managers could be hired by primary care offices or other community agencies. Insurance companies sometimes place care managers in primary care practices. Aetna embedded nurse care managers in primary care offices for Medicare Advantange patients and realized improvements in care processes, outcomes, and a reduction in hospitalizations (Hostetter, 2010).
The setting in which a care manager works impacts the care manager’s approach and how much of the his or her time is spent in direct contact with the care recipient and informal caregiver, versus completing service contacts and other administrative duties (Abendstern et al., 2019; Weinberg et al., 2003). In addition, the setting where a care manager is placed often reflects whether the care recipient and/or their caregiver have choices regarding whether or not to have a care manager, and what services will be received, when, and from whom (Hardy, Young, and Wistow, 1999).
‘Care management as a profession is not regulated at the state or federal level.’
Care management may be required to access particular services such as Medicaid waiver programs intended to prevent or delay nursing home placement. These nursing home diversion programs, often administered by AAA staff, require care management to receive publicly subsidized services such as home-delivered meals, personal care, or adult day services. The intent of these programs is to provide less costly care in the home with individual level cost caps. Insurance companies, on the other hand, may require individuals with particular chronic conditions to engage with a care manager for services, such as nutrition counseling for an individual with diabetes.
Managed care companies, which seek to ensure cost effectiveness of chronic disease and complex care management programs, include fewer choices around services received. In these cases, care managers often act as gatekeepers to more costly levels of care and carefully watch for services duplication. In other instances, individuals may seek care management on their own and hire a private care manager to more effectively navigate the complexities of long-term care services and supports. Often referred to as geriatric care managers, these individuals, who are primarily paid an hourly rate, can be costly and only accessible for middle and higher income individuals. Because these people are hired by the individual or by family members, accessing needed services tends to take priority over cost containment.
Who Are the Care Managers?
Care management as a profession is not regulated at the state or federal level. Care managers come from a variety of professional backgrounds such as nursing, social work, gerontology, pharmacy, dietetics, health coaching, or faith-based professions and have different levels of formal education or training, from high school diplomas to graduate degrees. The educational background of care managers is typically driven by practice resources, funding rules and regulations, and the needs of the target populations they serve (Farrell et al., 2015; Morano and Morano, 2006). Some care managers have state-level, discipline-specific certifications or licensure, while others do not. Discipline-specific licensing, such as in nursing or social work, requires care managers to demonstrate practice competencies through a standardized test, receive ongoing continuing education, and remain accountable to state licensing boards related to a set standard of care. Also, certified or licensed professionals practice under a code of ethics to which they must adhere to maintain licensure or certification.
On a national level, care managers can elect to become certified through the National Academy of Certified Care Managers (NACCM). This nonprofit organization certifies care managers who meet particular educational standards, care management experience, direct client contact, and pass a standardized exam (The National Academy of Certified Care Managers, 2016). Much like discipline-specific practice licensure and registration, certified care managers must adhere to a code of ethics, standards of practice, and keep skills current through continuing education requirements. Unlike discipline-based care managers (i.e., those in nursing and social work), these care associations are not linked to specific accredited university-based curriculum requirements. Instead, the majority of those with certifications add to their existing practice-based professional credentials or aging-related social science studies such as gerontology or psychology.
State and Program Rules About Care Managers
There are very few, if any, state or federal regulations related to privately funded care managers. Anyone who practices care management for private pay clients may do so, regardless of background or training. However, that is not the case when care managers are taking care of older adults supported through public funding such as Medicaid and Medicare. Two care management programs serving older adults in the United States are the 1915c Medicaid Home- and Community-based Services (HCBS) Waiver programs (long-term care) and the Medicare Chronic Care Management program (primary care). First available in 1981, the Medicaid HCBS Waiver programs are established by individual states under broad federal guidelines.
The intent of these waivers is to provide long-term care services and supports HCBS for individuals who qualify for Medicaid-funded institutional care at lower cost than nursing home care. HCBS Waiver programs recognize the desire of older adults to age outside of institutions and contain costs. Individuals who qualify for the programs through means-testing and level-of-care needs have care managers, referred to as case managers in statute. Each state determines who can act as care managers, which varies significantly state to state. The state of Ohio requires long-term care waiver case managers to be licensed social workers or registered nurses, while other states require a bachelor’s degree in a related area of study.
Beginning in 2015, the Centers for Medicare & Medicaid Services (CMS) began to use Medicare reimbursement for care management services in select instances. Medicare recipients with two or more chronic health conditions lasting at least twelve months, which put them at risk of functional decline or death, could receive care management.
This Medicare Chronic Care Management program is based in primary care and is delivered to older adults by physicians, clinical nurse specialists, nurse practitioners, or physician assistants. Federally qualified healthcare centers, rural health clinics, and critical access hospitals also can receive payment through the Medicare Chronic Care Management program. The addition of billable codes for care management marks a significant development in healthcare delivery, as it recognizes care management as a valuable and reimbursable healthcare service for individuals of various levels of income and assets (CMS, 2019).
Across the United States, primary, acute, and long-term care services and supports have long been criticized for a lack of coordination and comprehensiveness. Care managers are needed precisely because of this lack of coordination. With the number of older adults and individuals with disabilities growing, and healthcare expenditures skyrocketing, efforts to increase coordination across care systems has received increased attention. New models are being tested for cost containment, improvement in patient outcomes, and customer satisfaction. In the Ohio MyCare Demonstration project, the Ohio Department of Medicaid mandated health plans to partner with AAAs to provide care management to individuals who qualify for Medicare and Medicaid (Applebaum et al., 2019). The MyCare program uses two models of care management. In the waiver service coordination model, a care manager employed by a health plan is considered the primary care manager and is responsible for coordinating and monitoring all physical and behavioral health services across primary care, acute care, and long-term care. A waiver service coordinator employed at the AAA coordinates HCBS services historically provided through the Medicaid waiver, such as personal care, durable medical equipment, and transportation.
The health plan care manager and the AAA waiver service coordinator work in tandem to ensure that individuals’ needs are met across the full continuum of services. Three of the five MyCare health plans currently use the waiver service coordination model. The other two health plans use a fully delegated care management model in which one care manager employed by the AAA holds full responsibility for coordinating and monitoring all the individual’s needs across acute and long-term care, behavioral health, and HCBS services (Applebaum et al., 2019).
Future of Care Management
It is difficult to estimate the current number of care managers in the United States because of the significant variability in job titles, responsibilities, payment sources, and work settings. However, the U.S. Bureau of Labor Statistics estimates that in 2019 there were 175,500 social and community service managers, and it predicts a 17 percent increase in job growth over the next ten years—a much faster growth rate than the 4 percent average for all occupations (Bureau of Labor Statistics, 2020).
It is safe to say that the need for care managers is greater than the supply, as the number of individuals interested in aging-focused practice fields has not grown but the number of older adults and individuals living with disabilities has increased substantially. The shortage of health and social service practitioners specializing in aging is reflected in both licensed professions, such as physicians, nurses, and social workers, and non-licensed professions, such as direct care workers (nursing assistants, home health aides).
To counter stereotypes and myths, experiential curriculum in aging is needed in primary schools through higher education.
Challenges in recruiting students in these areas reflect stereotyping of older adults, an aging workforce, and financial disincentives (Institute of Medicine Committee on the Future Health Care Workforce for Older Americans, 2008). Direct care worker shortages directly impact the ability of care managers to effectively address the needs of older adults with disabilities and those who care for them. States are trying to respond to this shortage by increasing wages and benefits for direct care workers working in Medicaid programs and implementing workforce development plans to increase recruitment, retention and training (Gifford et. al, 2018).
Increasing the number of care managers in the future will require changing workforce development activities, not simply trying harder. Government, private industry and higher education need to try differently. Incentives such as low interest loans and tuition subsidies for students committed to working with older adult populations post-graduation may influence the pipeline of workers.
Recognizing that working with older adults and individuals with disabilities requires unique skills and often more time, private insurance companies could provide financial incentives for care managers of older adults, as more and better trained workers can have a positive impact on their bottom line.
Institutions of higher learning need to hire more faculty in the field of aging and engage in aggressive recruitment efforts in secondary schools via educating students about the high demand for care managers in the public and private job market.
To counter stereotypes and myths around aging, experiential curriculum related to issues in aging is needed in primary schools through higher education. With family members of different generations living further apart, there are fewer opportunities for positive interactions with older relatives. As our reliance upon digital media increases, so do the negative images of aging. This, along with a lack of exposure to older people, perpetuates negative stereotypes and has a detrimental impact on the number of people interested in studying aging and ultimately care management.
Our workforce is aging (Collins, Fischer, and Kelley, 2017). Many older people are remaining in the workforce by choice or due to financial necessity. This demographic shift in the workforce presents opportunities for retraining workers for care management positions. Institutions of higher education could provide opportunities for re-training college educated workers to gain the skills and credentials necessary to provide care management.
Flexible work schedules and the ability to implement what many older workers have likely experienced in their own lives as they have cared for family members may provide a helpful pipeline for workers. Some retirees may be interested in volunteering their time to provide care management as a way to create purpose and meaning in their lives.
Across public and private sectors, there is a significant amount of variability related to the training and preparation of care managers and where they may work. The population of people who could benefit from care management, however, seems clearer—those older adults who are facing chronic conditions that require access to and coordination across complex care systems.
Variability in state and federal rules related to care managers may allow for multiple populations to have their needs served, but creates challenges in demonstrating how we define care management and how it can benefit the health and well-being of older adults and their caregivers, as well as whether and how it reduces healthcare costs.
A shortage in the number of care managers exacerbates the challenges associated with documenting the outcomes of care management. Government, private industry, and higher education have the opportunity to implement creative solutions that will increase the number of care managers available, while more clearly defining educational requirements and practice protocols.
Holly Dabelko-Schoeny, MSW, PhD, is an associate professor in the College of Social Work, and Sara A. Moss-Pech, MA, is a doctoral candidate in the Department of Psychology, both at The Ohio State University in Columbus, Ohio. They can be contacted at Dabelkofirstname.lastname@example.org; and email@example.com.
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