The health care industry in the United States is continually changing, trying to meet the demands for quality, cost-effective care. Christensen and Bender (1994) note, “Changes promised by the evolving health care system promise to be broader and more wide-ranging than any other health care reform in recent history”. Consumerism is demanding that health care become more affordable, more quality focused, and more easily accessed. Empowered by knowledge, health care consumers will more strongly advocate for the provision of lower cost, more easily accessed, quality health care services, and health care providers will somehow have to try to meet these needs. However, there is a problem. The twenty-first century will see the beginning of the baby boomers reaching the age when they will need to utilize health care services more frequently. With this happening, the already precarious health care industry will have to grow larger to meet the health care needs of this population. As the health care industry grows, so will its financial requirements. Correspondingly, as has been demonstrated in the past, the budget-minded governmental agencies as well as the financially stressed third party payers will further tighten their purse strings and ask that more be done for less. This will cause increased importance to be placed on managing health care resources utilized by the health care provider.

          As the health care industry continues to change, individual health care provider’s efforts will more heavily concentrate on providing quality, cost effective health care services. The benefits of the provided health care services will be more closely scrutinized, and these benefits will be meticulously weighed against the costs they incur. Roberts-DeGennaro (1993) writes, “As a consequence, governmental regulations will continue to mandate clearer program accountability and documentation to prove that public funds are being efficiently used for human services programs”. This heightened accentuation on cost containment will induce health care providers to be innovative when seeking alternative methods for delivering quality care within an ever-tightening health care service budget. Health care providers will be looking for competent approaches to managing the use of health care resources and services. All health care providers, including nurses, will be asked to do more with even less. Health care reform, with its demand for the provision of quality care within a close-fisted budget, will obligate nurses to respond with more creative techniques for providing high quality care with minimal resources.

          According to Christensen and Bender (1994), “the conflict between quality and cost will present nurses with unprecedented challenges. The traditional role of the nurse will continue to evolve and change”. Johnson and Proffitt (1995) site that the results of over 200 nurses surveyed by Hospital & Health Networks showed that the majority of the nurses polled concurred that nursing’s delivery, management, and economic role, with regard to the provision of health care services, will become more significant in the future. Johnson and Proffitt (1995) further site that the nurses in the Hospital & Health Networks survey shared their belief that the number of patients being case managed will increase ten times over by the new century. Health care spectators are projecting that the twenty-first century will see that all nurses will, in all probability, practice case management in some form or another (Rawsky, 1996). Because the focus of all forms of nursing case management is the provision of quality care within a set budget, a nursing case management model for patient care delivery will most likely play an important role in what lies ahead for health care in the twenty-first century and beyond. Cohen and Cesta (1994) comment, “By encompassing innovation and versatility, case management offers the framework to provide competent patient care and to manage services in the new health care system”.

          Nursing case management provides a road map for health care delivery by delineating what needs to be done for and with the patient and by setting realistic, measurable goals. Milne and Pelletier (1994) comment, “As the 21st century approaches, the nurse’s ability to adequately plan complex patient care requirements becomes increasingly critical” (p. 160). Nursing case management aligns nurses with other nurses, with physicians, and with other health care disciplines, across hospital units and departments. Ritter et al (1992) write, “Nurses practicing as case managers have the opportunity to function in a highly professional, independent manner with a great deal of interdisciplinary collaboration”. Because nursing case management places importance on predictability, a degree of control of practice is added and clinician isolation is decreased. With the assistance of DRGs, nursing case management provides a common understanding of health care benefits between health care providers and health care consumers and transforms patient problems into measurable, realistic patient goals that are important to the patient and the patient’s support person(s). Ritter et al (1992) observe, “Nurse case managers manage hospital systems to produce optimal clinical outcomes for patients in the shortest time using as few resources as possible. This approach to care delivery places nurses in a position to demonstrate the tremendous contribution they can make to achieving the institution’s goal of delivering high-quality, cost-effective care” . Because of what it already does and as it continues to grow and fully develop, nursing case management will have the ability to promote the connection between health care institutions and larger health care delivery systems (Zander, 1988).

          It is predicted, that in the twenty-first century, case management practice will be molded primarily by the needs and demands of the health care consumer (Roberts-DeGennaro, 1993). Therefore, it will be very important for the nurse case manager to understand exactly what the needs of the community to be served are (Rubadue, 1996). Wojner (1997) writes, “The future of health care in the United States will best be served by a movement to patient-driven services” (p. 3). And, who better to manage those services than the nurse case manager who is intimately involved in the care of the patient? It is expected that nursing case management will span the health care continuum from acute care to subacute care, to home and community care, to long-term care (Cohen & Cesta, 1994). (See Figure 9-1.) This expectation promises abundant opportunities for nurse case managers to influence how quality care is delivered across all patient care settings within the cost conscious health care industry. Ritter et al (1992) write, “Given the financial environment and the need to balance the cost/quality equation, case management will become increasingly important and has the potential to become the predominant care delivery system…” in the managed care environment.

          Block (1997) writes, “Managed care plans now make up 81% of nationwide enrollment of those with health care coverage, as compared with 74% in 1996 and 29% in 1988 and,…the accelerating movement to managed care is predicted to continue”. Cohen and Cesta (1994) opine, “The future viability of acute care facilities is dependent on their ability to capture the greatest managed care market share”. Managed care undoubtedly affects the delivery of effective health care. Managed care combines the delivery of health care services with health care financing so that the financial burden for choice of health care resources is placed equally on both the health care consumer and the health care provider. By more openly linking the provision of health care services with the financial aspects of health care delivery and by making the health care consumer and the health care provider more responsible for the outcomes of health care service choices, managed care profoundly influences all aspects of health care provision including access to health care services, individual courses of treatment, and the structure of health care delivery itself.

          Health care today is a business and will always continue to be so. Even not-for-profit health care institutions are in business – the business of staying open and available for the provision of health care services. In realizing this, nurses “…need to learn to be good business leaders (and)… need to be business partners and expand our knowledge as business minded clinicians” (Rubadue, 1996). Not only must nurses focus on becoming more business minded, but they must also acquire skills that enable them to competently assess the effectiveness of the health care services being provided to the patient. Becoming familiar with computer programs and institutional information systems will be helpful when wanting to process data that will show the effectiveness of health care services rendered.

          In the budget-minded managed care environment costly specialization will continue to decrease; therefore, nurses will be asked to revert back to performing duties that were once carried out by bedside nurses and then, with specialization, became the responsibility of specialty nurses and/or other hospital departments (Christensen & Bender, 1994). These duties can include, but are not limited to, discharge planning, intravenous catheter starts and restarts, complex wound care, simple respiratory therapies, and some physical therapy. Correspondingly, so that they can take on added responsibilities, nurses will have to get used to the idea that other health care disciplines will be taking on tasks that were once considered to be solely nursing functions, such as zeroing intravenous pumps at the end of shift or performing simple dressing changes (Christensen & Bender, 1994). Although other health care disciplines will be responsible for performing these duties, nursing will still be accountable for overseeing task completion. Nurses will need to become even more flexible; will need to be very open to cross training; and will need to learn to work in multi-disciplinary teams (Rubadue, 1996). Christensen and Bender (1994) foresee that, “Nurses will be called on to perform more duties across disciplines. …Nurses will continue to be challenged to provide a wider variety of services requiring increased knowledge” (p. 69). Furthermore, nurses need to concentrate on developing their administrative skills and need to continue to sharpen their leadership skills to further the evolution of innovative and resourceful case management programs.

          As the population in the United States grows older, it will become necessary for case management programs to extend beyond the walls of the hospital (Anderson-Loftin et al, 1995). A nurse case manager who could efficiently function in both the hospital and community settings would bring a higher rate of continuity of care to the health care consumer. This in turn would serve to decrease extended hospital stays and readmission rates while preventing unneeded hospital admissions. Anderson-Loftin et al (1995) write, “Unnecessary hospitalizations would be prevented, and early intervention by case managers would mean that patients whose admission was necessary would be admitted at a lower acuity. Physicians would benefit by decreased telephone calls from patients and families, increased patient satisfaction, and decreased patient emergencies”.

          Two relatively new case management programs that nurses will probably become even more involved with as the programs continue to evolve are disease state management and demand management. Disease state management was introduced in the late 1980s, and Coleman and Zagor (1998) note, “Disease state management is often referred to as the next generation of managed care because it takes the concepts of improving cost, quality and access one step further by targeting chronic, costly medical conditions (such as hypertension, diabetes, and chronic obstructive pulmonary disease) that require long-term care solutions. Disease state management is an integrated, multidisciplinary approach to patient care that coordinates resources across the entire health care delivery system”). Successful disease state management programs also focus on providing patient education to promote healthy lifestyles (IBID). Intercomparable to case management, disease state management, advocates that health care consumers be responsible for and intimately involved in the health care choices that will serve to maintain or improve their health state (Coleman & Zagor, 1998). “…Disease state management, like case management, requires a multidisciplinary, multi-power approach aimed at satisfying the total health care needs of each patient. To be effective long-term, the therapeutic disease state management approach must have early intervention in the prevention, diagnosis, education, and management of the target disease in the covered population” (IBID). Prosperous disease state management programs have proven to be successful because they intervene with appropriate medical, nursing, and pharmaceutical actions early in the course of the disease process (Coleman & Zagor, 1998). By intervening early in the course of the disease process, disease state management programs are able to achieve control of and treat the disease process when health care expenses are more reasonable and budget-conserving health care service alternatives are more accessible to fight the symptoms of the disease process (IBID).

          According to Coleman and Zagor (1998), demand management strategies started to emerge in the early 1990s, and they are “touted by many to be the newest generation of case management”. Demand management centers on providing health maintenance and health care information to health care consumers in order that they may maintain themselves in a healthy state and have the knowledge to make appropriate health care utilization decisions (IBID). Demand management’s resource information includes health maintenance and care self-help literature and referrals to self-care related health books that enable the demand management subscriber “…to make more responsible self-care, triage, and treatment decisions” (IBID). The information is primarily made available to demand management subscribers through telephone contact or Internet connections (Coleman & Zagor, 1998). The information demands of health care consumers indicate they are ready to accept more responsibility for managing their own health state (IBID). This acceptance of responsibility imposes an obligation on health care coverage programs to provide health care consumers with access to the resources they need to care for themselves and their significant others (Coleman & Zagor, 1998).

          Demand management programs also provide wellness and health promotion programs so that health care consumers can attain healthier lifestyles by developing better health habits (IBID). “Demand management programs now provide an estimated 35 million enrollees with the right information to care for themselves and guides them in making positive lifestyle and health seeking behavior changes that result in improved health status… The clinical literature is now beginning to show that combining case management with demand management results in patients that are better educated and who make fewer and less invasive demands on the health care system” (Coleman & Zagor, 1998).

          The budget minded, quality focused, health care consumer centered concept of providing health care services is here to stay and requires nurses who expect to be involved in the future provision of health care services to somewhat modify their standard operations. Health care is moving even more toward service provision in outpatient and community settings and is placing a greater emphasis on wellness. The future will see the institution of higher health care technology as well as more weight being placed upon the provision of treatment at lower levels of care. Nurses who wish to practice in the future need to be even more flexible, need to increase their knowledge base, need to be amenable to continual change, and need to possess competent leadership skills. Opportunities exist for building an auspicious future in which health care consumers participate in and receive quality care; nurses experience satisfaction for a job well done; and the institution where health care is being provided reaches a satisfactory financial plateau.

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