Case Management

Case management is not a new model for the delivery of patient care. The concept of case management has been around for a long time. (See Figure 1-1.) The roots of case management in the United States date back to just 

Figure 1-1 Case Management Time Line 1863  Massachusetts began its Board of Charities. 1877  Charity Organization Societies became dominant in providing services to the poor. 1889  Chicago’s Hull House was founded. 1890s  Lillian Wald founded American public (community) health nursing. Early  U.S. Public Health Service 1900s  designed an early case management system. Lillian Wald convinced Metropolitan Life Insurance Company to organize a visiting nurse program. By 1909  All states had developed some form of health department. 1910  Thomas Curan and James Yocum contracted with the lumbar industry to take care of employee health for 50 cents per employee per month. Mid 1920s  Child guidance centers were set up. 1929  Blue Cross and hospital insurance originated in Texas. The Ross-Loos Clinic was formed. Mid 1930s  The Social Security Act made funds available for taking care of individual client health care needs. 1934  Kaiser health care emerged. 1938  Lillian Wald founded the Henry Street Settlement House. 1960s  The Civil Rights Movement made a major impact on the refinement of case management. 1970s  Client-level coordination and the term “Case Management” emerged. 1972  The Allied Services Act addressed Case Management. 1980s  DRGs, prospective payment systems, HMOs, and PPOs came into play. Utilization Management and Discharge Planning emerged. Karen Zander established the Nursing Case Management Model which included the use of care maps and critical pathways. 1987  Medicare Nursing Practice and Patient Care Improvement Act designated nurses as case managers in federal case management programs. 1989  The Healthy Birth Act designated nurses as case managers in federal case management programs.

before the turn of the century. The evolvement of case management can be credited to the industrial age during which city populations began to skyrocket. As the numbers of people in the cities began to grow, so did the size and organization of health care and social service. These changes resulted in fragmentation and duplication of health and human services.

         The method of case management can be tracked back to the 1860s when primitive case management delivery systems were developed as a result of the fast growing urban populations and the uncoordinated health and human services that were being provided to the sick, poor and underprivileged. This underserved population included a vast number of immigrants entering the United States at the time. The establishment of this early case management care delivery system could also be attributed to the need for conservation of public funds and a desire for competent, quality, cost-effective coordination and provision of social and health care services (Conti, 1996).

         The state of Massachusetts can be credited with beginning the first board of charities in the United States. Massachusetts began its board of charities in 1863. This board of charities was charged with helping coordinate public services for the sick and needy while at the same time conserving public funds (Kersbergen, 1996). Each family’s needs along with any neighborhood concerns and environmental issues were kept on file for management of needed services. Service at this time focused on the need for the development and delivery of quality services for the underprivileged populations. This service model contained an advocacy component.  This advocacy component was very important especially for the immigrants pouring into the United States, as they had difficulty obtaining the assistance they needed.

          “In 1877, the first major effort at interagency cooperation and coordination resulted from the Charity Organization Societies, which became a dominant force in providing services to the poor while emphasizing the need to deliver services in a cost-effective, efficient manner” (Kersbergen, 1996). The coordination of public services for immigrants and the poor was set up to avoid duplication of health and social services. “Case management is rooted in a long history social work efforts for service coordination, such as Chicago’s Hull House, founded in 1889 to offer a variety of programs for immigrant populations” (Conti, 1996). This community service focus centered on educating individuals and families on self-care to provide them with a better sense of well-being and an avenue to take care of their own needs. It was a grass roots effort for preventive healthcare and wellness.

          In the early 1900s the United States Public Health Service designed an early case management system. This case management system was initially set up to assist the community in dealing with problems such as immunization and sanitation practices (Kersbergen, 1996). “By 1909 all of the states had developed some form of health department…” (Kersbergen, 1996). In the mid 1920s, in an effort to care for needy children, child guidance centers were set up. These child guidance centers provided a multidisciplinary approach to planning and implementing needed health and human services with a focus on avoiding duplication and fragmentation (Kersbergen, 1996). In the mid 1930s, the Social Security Act made funds available that provided for taking care of individual client health care needs. After World War II, a system for ensuring a continuum of care was set up for providing extended services to discharged psychiatric patients (Johnson & Proffitt, 1995).

          A major impact on the refinement of case management was the Civil Rights Movement (Kersbergen, 1996). Clients were no longer happy with being passive receptors of health care. They were instead learning to become active consumers of health care. “In the 1960s the term (case management) was used to describe programs designed to promote coordination of services” (Johnson & Proffitt, 1995). The coordination of services programs of the 1960s developed into client-level coordination in the 1970s (Conti, 1996). The first congressional initiative to address case management was the Allied Services Act of 1972. This act “…required that social service programs be consolidated, offer a full range of services, and increase access to care” (Conti, 1996). The term “case management” first emerged in social welfare literature and practice in the early 1970s.

          “The expansion of case management beyond mental health and into other health care arenas has been related to rapidly escalating costs of health care and the prospective payment systems of the 1980s” (Kersbergen, 1996). In 1984, due to the introduction of Diagnosis-Related Groups (DRGs) for the Medicare population and other third-party payer cost-reduction strategies, “…the focus of case management began to shift toward providing more efficient and cost-effective patient care while maintaining high quality and acceptable patient outcomes” (Johnson & Proffitt, 1995). DRGs were set up to pay for care by the case rather than the services provided; thereby, creating reimbursement incentives for decreased lengths of stay. Case management became a method for ensuring timely discharge with a focus on prevention of resource wasting and duplication of services.

          At the same time that hospitals were setting up case management programs, insurance companies were doing the same thing. However, the focus of case management in the insurance industry was on controlling cost by investigating the needed health care and the delivery of such. The initial focus of this type of case management was to coordinate care for clients with high cost or long-term illnesses. “The emergence of health maintenance organizations (HMOs) and preferred provider organizations (PPOs) in the 1980s provided another source of prepaid health care to compete with the health insurance industry. The structure of HMOs and PPOs provided additional incentives for controlling costs through coordination of care provided” (Kersbergen, 1996). 

          Case management approaches employed by HMOs were designed to control usage and costs while managing all of the healthcare needs of their clients. Because of the potential cost containment they could provide, the rapid growth of HMOs and PPOs in the mid 1980s was fully supported by employers and the government. “In the 1980s insurance companies, health maintenance organizations, preferred provider organizations, and industries identified the need to manage clients within ‘catastrophic’ case types” (Stiller & Brown, 1996). “Case management, medical case management, comprehensive case management, catastrophic case management and nursing case management were relatively new concepts in the young field of managed care in the 1980s” (Coleman & Zagor, 1998). 

Nursing Case Management

          Nursing case management in the form of community health nursing took its cue from community service coordination for delivering health care services to the poor and underprivileged as well as the immigrant populations. “Community health nursing has a rich history of using a form of case management to focus on the multiple needs of clients and coordinate care” (Kersbergen, 1996). Lillian Wald founded American public (community) health nursing in the 1890s (Kersbergen, 1996). Ms. Wald’s focus in developing this type of nursing service was to help clients make independent health choices by educating them about available resources. “The early Public Health Nurse practiced autonomously to organize and mobilize family and community resources while providing direct nursing care as needed” (Kersbergen, 1996). 

          In the early 1900s Ms. Wald convinced Metropolitan Life Insurance Company to organize a visiting nurse program which would provide nursing case management services to its ill policyholders. Ms. Wald contended that by providing sick policy holders with nursing case management services, Metropolitan Life Insurance Company would put off having to pay costly death benefits. “By 1925, this nurse case management system had saved Metropolitan Life Insurance Company an estimated $43,000,000” (Kersbergen, 1996). In 1938 Ms. Wald founded the Henry Street Settlement House which offered a number of nursing managed services to the needy ( Conti, 1996). Nursing case management grew and flourished in the community setting from its beginning with Lillian Wald. 

          From the early 1970s to 1990 the On Look Project in San Francisco provided community nursing case management services to dependent elderly individuals who were eligible for nursing home care (Cohen & Cesta, 1994). From the mid 1970s to the late 1970s, the Wisconsin Community Care Organization provided community nursing case management services for geriatric individuals who were at risk for institutionalization (IBID). In Connecticut from the mid-1970s to 1980, nurses participated in conjunction with social workers to provide community case management and health care services that fell outside of the traditional Medicare benefits through the Triage Project (Cohen & Cesta, 1994). From the mid 1970s to 1990, New York’s Access Project extended community case management nursing services to all individuals who were 18 years of age or older and Medicare recipients over the age of 65 years who needed long-term, skilled nursing care (IBID). During the early 1980s to the late 1980s, the Long-Term Care Channeling Demonstration Project offered community nursing case management services in ten states to “…dependent and chronically ill individuals, impaired elderly, and those at risk for institutionalization” (Cohen & Cesta, 1994). Although possibly not realizing it, nurses in other health care arenas have been practicing a form of nursing case management from the time of Florence Nightingale to the present day in the form of the Nursing Process.

          In the mid 1980s, nursing case management in the form of discharge planning and utilization review emerged for dealing with restraints imposed by DRGs and third party payer resource conservation requirements. As nurses worked closely with the patient population and had firm knowledge of the care needed, they were the obvious choice to fill the discharge planning and utilization review roles. Karen Zander, a registered nurse at the New England Medical Center in Boston established the Nursing Case Management Model in the 1980s. Karen Zander’s model of nursing case management included the employment of two tools, a “care map” and a “critical pathway.” The use of these tools was intended to move the patient along a healing continuum toward discharge within a specified timeframe while providing a means for documentation of the patient’s progress or lack of progress.

          “Nurses were not designated as case managers in federal case management programs or demonstration projects until the 1987 Medicare Nursing Practice and Patient Care Improvement Act and the 1989 Healthy Birth Act” (Conti, 1996). 

Managed Care

          Managed care is not a new concept and also has its roots in the social service arena. In 1910, Thomas Curran and James Yocum, two physicians, contracted with the lumbar industry to take care of employee healthcare for 50 cents per employee per month (Block, 1997). “The concept of prepaid care evolved largely because of the many immigrants who in the 1800s came to the United States to work in isolated areas of the country. The people who employed them, by necessity, pioneered capitated healthcare and other innovative healthcare arrangements” (Block, 1997). Some of the physicians employed by the various industries were paid a salary while others were paid a flat fee per employee.

          “In 1929, the same year that Blue Cross and hospital insurance originated in Dallas, Texas, employees of the Los Angeles Department of Water and Power arranged with two physicians, Donald Ross and H. Clifford Loos, to provide them with comprehensive services – both medical and hospital” (Block, 1997). Six years after its formation, the Ross-Loos Clinic was providing care at substantially below the costs most Californians were paying for other health care means (Block, 1997). Also in 1929, a physician, Michael Shadid, proposed a prepaid physician cooperative health plan in Elk City, Oklahoma. This cooperative was so successful that other prepaid physician cooperatives were set up all over the United States in ensuing years (Block, 1997). Michael Shadid can be considered the original founder of HMOs.

          The Kaiser HMO came about when, in 1934, a young physician who had built a small hospital in a California desert town was contracted by an insurance company founded by Henry Kaiser to provide prepaid health care for the employees of the Metropolitan Water District (Block, 1997). When the Grand Coulee Dam in Washington was under construction, Dr. Garfield was once again contracted by Henry Kaiser to provide prepaid health care for his employees and their families (Block, 1997). “During World War II, Kaiser discovered that workers with health care were more productive, so he invited Garfield to his Bay Area California shipbuilding and steel mill ventures to begin another plan...the Permanente Health Plan” (Block, 1997).

          “By the late 1970s, two other models of managed care, IPAs and network model HMOs had emerged in response to physicians’ concerns about perceived threats posed by group and staff models” (Block, 1997). As employers began to see the benefits and cost savings provided by managed care plans, the late 1980s saw a growth in the number of available managed care plans. All levels of government agencies as well as big business began to adopt managed care as the answer to rising health care costs.


Summary

          For over one hundred years case management has been practiced by the social service disciplines and nursing to coordinate health care and human services in the United States. Since its beginning, case management has continued to be refined and improved upon, but its underlying premise – the insurance of quality, cost-effective care has not changed. Managed care has existed for almost as long as case management and also has as its underlying premise the desire to provide quality care for all while supporting cost containment.


REFERENCES

Block, L. (1997). Evolution, growth, and status of managed care in the United States. Public Health Reviews, 25, 195-239.

Coleman, J., Zagor, B. (1998). Effective care management. Continuing Care, July/August, 23-29.

Conti, R. (1996). Nurse case manager roles: Implications for practice and education. Nursing Administration Quarterly, 21(1), 67-80.

Johnson, K., Proffitt, N. (1995). A decentralized model for case management. Nursing Economics, 13(3), 142-151.

Kersbergen, A. (1996). Case management: A rich history of coordinating care to control costs. Nursing Outlook, 44(4), 169-172.

Stiller, A., Brown, H. 91996). Case management: Implementing the vision. Nursing Economics, 14(1), 9-13.