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The Impact of COVID-19 and the Critical Need for Case Management

Geld, Bonnie MSW

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doi: 10.1097/NCM.0000000000000462
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The global coronavirus disease 2019 (COVID-19) pandemic will have significant impacts for both health systems and patients (World Health Organization, 2020). It is clear there will be economic, clinical, and psychosocial consequences, among others. Although these consequences continue to be better understood, especially the magnitude of the financial losses to hospitals (Ellison, 2020), the silver lining during this pandemic is that new and creative innovative ways to connect and support patients are now occurring. It is remarkable to witness how these innovative ways have been implemented in a short amount of time. Although there will continue to be unique and more traditional elements of care, the COVID-19 pandemic is demonstrating how “new models” in health care, such as virtual patient care and digital outreach, can be more readily available to patients. Case Managers and Social workers will be essential in their duties in coordinating care, supporting patients in the management of chronic illness and post hospital care, and advocacy and interventions in social determinants of health.

As health systems come back on line during and after the COVID-19 pandemic and health systems have a resurgence of patient volumes, there will need to be ongoing screening and assessment of COVID-19 patients. For example, COVID-19 contact tracing has begun in the Commonwealth of Massachusetts in which they are employing more than 1,000 team members to provide tracing and then case management to individuals who will require follow-up support and care. This is a unique collaborative between the Commonwealth and Partners in Health (PIH). It is clear to them that some patients will require more support in recovery and are putting social workers and case managers in place to provide this in the short term (PIH, 2020). These patients will continue to create both risks in a variety of care settings and risks in discharge delays. Capacity will become even more at a premium, so decreasing length of stay to ensure capacity availability for all will be mission critical. In addition, there will likely be a spike in homelessness, Medicaid beneficiaries, and the uninsured. According to an article published by Kaiser Family Foundation, COVID-19 will result in increased unemployment and present serious challenges to Medicaid and coverage for uninsured individuals (Politz & Claxton, 2020). All of these issues will impact the health system and depend on efficient care. Professional case managers (both registered nurses [RNs] and social workers) will be required to keep their uniquely qualified eyes on length of stay and, at the same time, quickly address new and even more compromising Social Determinants of Health.

Patients will begin to experience new and continued scheduling challenges, when access is permitted, in an attempt to get their long-awaited elective surgeries and face-to-face physicians' visits scheduled, thereby making access to care problematic. Some may actually opt for telehealth services they were receiving during COVID-19 lockdown. “Research shows that that patients generally like telemedicine, but a new Cleveland Clinic study delves deeper into why it's a hit.... The nationwide study analyzed data from 28,222 medical encounters between 24,040 patients and 277 physicians” (Cleveland Clinic, 2019, p. 1). Health literacy and emotional wellness have been tested during this crisis and will have consequences to emotional health into the future. In my opinion, social workers are uniquely qualified to support patients in this area and teach new forms of coping; communicating and consoling will be important and consequential.

Case Management Is Essential

Consider the current roles of case managers and social workers. These teams are positioned to manage priorities before, during, and after times of crisis. Case managers have a comprehensive and large-scale patient-centered point of view, considering their patients' medical, psychological, social, and spiritual needs. They bring insight, strength, and calm to hospital teams, patients, and caregivers. Ensuring an effective and comprehensive case management team will be mission critical to address rebounding volumes of uninsured/Medicaid patients, increases in discharge delays or lengths of hospital stays, maintaining regulatory compliance, patient identification and outreach, denial and preauthorization management, emotional wellness, and an enhanced need for effective communication. The following reasons highlight the need for case management in this most unusual time.

Rebounding Volumes and Discharge Delays

Case managers must work closely with census and bed management, along with patient insurance verification to ensure timely authorizations in sync with bed availability. Case managers in the hospital, and at other entry points, are and will continue to be essential components of the care initiative. In addition, post-acute care facilities will become less available due to higher volumes of COVID-19 patient influx and must be addressed. It will be important to avoid “bed wars” between case managers, vying for the same bed. Collaboration is crucial. Box 1 illustrates the importance of working corroboratively with post acute care during these uncertain times. Case management skills and tools, such as triage and the components of assessment, are part of the case managers arsenal against overwhelming volume (Commission for Case Manager Certification [CCMC], 2020). New strategies and collaboration in triage, stratifying risk, and early discharge planning will be imperative. The increased demand for home-based care must also be evaluated along with greater collaboration with home care agencies.

BOX 1
BOX 1

Escalating Volumes in Uninsured and Medicaid Patients

The potential increase of patients needing assistance through federal government programs such as Medicaid, food assistance programs, disability, and other social safety net programs will require more resources from social workers and case managers. Not only this will impact patients who have lost their jobs and/or medical insurance but there will also likely be an increase in homelessness. Box 2 speaks to the impact on pediatrics and the medicaid program. It is an accepted fact that patients without insurance and/or are homeless have longer lengths of stay in the hospital and are more likely to seek care from a hospital rather than an alternate source, such as urgent care centers. This results in a higher incidence of readmissions and high volumes of unnecessary emergency department (ED) visits. Case management and social work can play a role here as well by interventions with patients dealing with homelessness. Case management screening, assessment, and stratification of need are key (CCMC, 2020).

BOX 2
BOX 2

Regulatory Compliance/Denials Management and Preauthorizations

As the Centers for Medicare & Medicaid Services brings regulatory requirements back online, it will be critical for hospitals, as well as case managers, to be aware of any regulatory changes and when regulatory compliance practices have resumed. It is possible that some of the regulatory requirements, such as 3-day inpatient stay, could be permanently eliminated. As elective surgeries return and hospitals need swift authorizations for these surgeries and the requisite post-acute care, case managers will be essential. Having case management support in place will help manage and mitigate the impact of denials and excessive back-end processes on patients and providers.

Patient Identification and Outreach

Case management and social work assessments will need to include a patient's COVID-19 history (including exposures and the aftercare received). Bolstering high-risk identification processes and handoffs to ambulatory services will allow case managers help patients avoid long-term follow-up and readmission. Identifying and outreach to patients in the immediate future are needed, potentially before a second wave of COVID-19 occurs.

Case management has been instrumental in connecting patients across the continuum of care (Geld, 2018). Accountable care organizations have been collaborating with hospitals and payers have been identifying patients for various programs such as pharmacy assistance and food insecurities, and home care entities have created the bridge through case management identification of need (Center for Healthcare and Social Integration, 2020).

Emotional Wellness and Mental Health Needs

Patients and their families will have potentially long-lasting psychological or psychosocial effects from the COVID-19 pandemic, especially if a person was infected or was isolated. Research from the Kaiser Family Foundation associates increased depression, anxiety, distress, and low self-esteem with job loss and extended illness (Politz & Claxton, 2020). As a consequence of these effects, it is likely that patients will witness social admissions, unnecessary ED visits, or delayed discharges. It is essential to arm the case management team with the social work tools and techniques to provide patient support and quickly identity the referral resources in the area. In addition, the overwhelmed systems facing ongoing and delayed chronic care patients will now feel more confident with the right case managers and social workers in place. This will not just affect the patients but also affect the team caring for these patients. Social workers are uniquely positioned to support the teams through collaborative interventions, critical incident debriefing, and other tactics in supporting individuals and teams through crisis.

Education and Teaching Tools

Covid-19 high-risk screening equals patient identification, which translates to opportunities across the care continuum. Case managers are highly empathetic, sympathetic, and insightful patient advocates and educators. They can prepare patients and families in ways to anticipate and address different approaches to manage their medical needs by making high-quality information available going forward. Because health systems and providers are gaining a better understanding of COVID-19 and the processes, program, providers, and tools that are essential, having experienced case managers and social workers in place to help educate, advocate, and teach families about their loved ones' medical needs is critically important.

Enhanced Expectations for Communication

There is no dispute that patient literacy improves patient engagement. There is, however, a significant gap in communications between health care providers and family members/caretakers. Understaffing and unclear expectations on the part of frontline personnel as to when and how information is communicated to family members and other caregivers and stakeholders must be addressed. As advocates, case managers, nurses, and social workers are excellent frontline communicators in these scenarios. Organizations need to continue using technology as a means of effective and efficient clinical service communication to patients, but for this to be successful, the case manager must identify whether the learner is able to understand the method of information delivery. Access to live interpreters, translation apps, or telephonic interpretation services are ways to advance understanding when English is not the patient's (or staff member's) primary language.

Over time, patients will become more accustomed to this form of communication. Telehealth, payer telephonic liaisons, community advocates, kiosks, and avatars are many of the existing tools of available for this population. Professional case managers, both RNs and social workers, have the patience and knowledge to communicate and assess the strengths of these tools to support families during this time (interview with S. Kates, Director of Case Management, Community Medical Center, April 2020; interviewer B.G.).

Conclusion

Professional case managers, nurses, and social workers have always supported patients and their families in times of crisis. They will take on these new and ever-evolving challenges of COVID-19 as well as a contemporary team member, partner, and patient advocate.

References

Center for Healthcare and Social Integration. (2020). The Bridge Model. Retrieved from the Center for Health and Social Care Integration website: https://transitionalcare.org/the-bridge-model
Cleveland Clinic. (2019, February 8). Cleveland Clinic Express Care® online. Retrieved from Cleveland Clinic website: https://my.clevelandclinic.org/online-services/express-care-online
Commission for Case Manager Certification (CCMC). (2020). Case management processes. Retrieved from CCMC BOK website: https://cmbodyofknowledge.com/content/case-management-processes
Ellison A. (2020, March 23). Hospitals face financial fallout from COVID-19: 6 things to know. Retrieved from https://www.beckershospitalreview.com/finance/hospitals-face-financial-fallout-from-covid-19-6-things-to-know.html
Flynn M. (2020, March 26). As COVID-19 surges, lack of tests complicates nursing homes' decision to admit or deny. Retrieved from Skilled Nursing News website: https://skillednursingnews.com/2020/03/as-covid-19-surges-lack-of-tests-complicates-nursing-homes-decision-to-admit-or-deny
    Geld B. (2018). Care transitions in case management I. Middleton, MA: HCPro.
    Partners in Health (PIH). (2020). Massachusetts response. Retrieved from Partners in Health website: https://www.pih.org/ma-response
    Politz K., Claxton G. (2020, April 14). Changes in Income and health coverage eligibility after job loss due to COVID-19. Retrieved from Kaiser Family Foundation website: https://www.kff.org/health-reform/issue-brief/changes-in-income-and-health-coverage-eligibility-after-job-loss-due-to-covid-19
    World Health Organization. (2020, April 23). Coronavirus disease 2019 (COVID-19) situation report—94. Retrieved from World Health Organization website: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200423-sitrep-94-covid-19.pdf?sfvrsn=b8304bf0_4
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