JUNE 10-14, 2019   •  Las Vegas, NV
Navigating the Full Spectrum of Case Management • Mirage Convention Center

PP210 – Transforming Care: Advanced Practice CM of High-Risk High-Cost Population

Jun 12 2019
12:30 pm - 2:30 pm

PP210 – Transforming Care: Advanced Practice CM of High-Risk High-Cost Population

Established in 1997, Community Based Case Management (CBCM) is a program of masters prepared nurses and social workers addressing the needs of vulnerable adults at high risk for readmission due to complex medical conditions often times intertwined with behavioral health concerns and complicated social determinants of health. CBCM engages clients in successfully navigating the health care system to achieve optimal self-determined health care goals. CBCM practitioners enhance the care of marginalized and vulnerable clients to lead the health care system in achieving the quadruple aim.
Advanced practice interventions include authentic engagement, comprehensive holistic assessment, patient-centered goal development, promotion of self-efficacy, establishment of collaborative relationships, resource mobilization, and moral agency. Services are provided in the home, provider offices, or in the community. The CBCM approach is unique in that care is provided without traditional system boundaries. CBCM receives requests for advanced practice activities beyond direct care. Examples include mentoring, coaching professional development, consulting, and contributing to evidence base knowledge. It provides leadership and a community perspective in system-wide initiatives.
CBCM consistently demonstrated results congruent with the Institute for Health Care Improvement. The 2017 Medicare impact included a 38% reduction in ED visits, 40% decrease in inpatient admissions, and a 50% reduction in 30 day readmits. Total annualized savings was $2M for the system. CBCM benefits include processes to promote patient centered goals, professional development of internal and external partners, and formal education on the care needs of vulnerable populations. CBCM impacts system processes, provider practice, model inclusion, bridge gaps in care, and inspire creative strategies. CBCM promotes the shift from care for the patient to care with the patient.


1. Describe the cost savings an advanced practice case management program produces for an organization.

2. Describe how a masters-prepared practitioner’s knowledge, skills, and abilities enhances case management outcomes.

3. Identify additional benefits advanced practitioners provide within the organization and the community.