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What is case management?
What is the case manager Role?
Where has case management come from, What are its origins?
Where are case managers found today ?
How do clients benefit from case management?
What is the case management process?
Who is a Case Manager?
There are challenges in describing a case manager in a way that satisfies everyone who works in or thinks about case management because the term "case manager" is commonly misused or used as an umbrella term. An inherent problem in discussing case management in a singular focused manner is that the terms "case management" and "case manager" have been used to describe many individuals that perform many different role functions. In addition, the concept of case management is as complex as expression of the case management process.
Many organizations in the U.S. today have changed from case management to care management as a basic term, partly due to the confusion with the term "case." The change of the name may help for a short time, but does not keep the real name clear that has been with healthcare areas for many years.
Definition of Case Management
The Case Management Society of America (CMSA), a non-profit, multidisciplinary society of case management professionals, defines case management as "a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes"(1995).
The underlying philosophy of case management, as set forth by the CMSA, asserts that all individuals, most notably those suffering from catastrophic and/or high risk or costly injuries or illnesses should have the services of a case manager regardless of the client's ability to pay.
Case management in these types of cases will help to identify care options which are most acceptable to the client and family, and promote compliance with the treatment plan and successful outcomes. In addition, case management can help to reduce fragmentation of care for those clients who receive healthcare from multiple providers. The services of a case manager are meant to enhance quality of life while reducing overall healthcare costs, and thus, case managers impact in a positive manner the health and well-being "of the entire country and its population" (CMSA). While this philosophy speaks to case management in the U.S., it is evident that well-developed case management services can have a positive influence on care across borders and around the world.
Role of the Case Manager
The role of the case manager is to "collaborate with clients by assessing, Facilitating, planning and advocating for health needs on an individual basis. Successful outcomes cannot be achieved without specialized skills and knowledge applied throughout the process" (CMSA). The specialized skills for effective case management include expertise in several areas that are the standard of professional case management. These specialized skills are listed in Table 1.
To better understand the role confusion and purpose of case management, a look at the history of case management is important. While many leaders may point only to the community roles of case management in the past, it is also necessary to review hospital roles and third-party roles that have become part of the case management profession.
Brief Historical Roots of Case Management
Case management has been around in this country for nearly one hundred years. In the early 1900's case managers were public health nurses and social workers who coordinated services through the public health sector. After World War II, insurance companies began to use nurses and social workers in the coordination of care and services for soldiers returning from the war who suffered complex injuries that required multiple interventions.
The current models of case management evolved in response to the Medicaid and Medicare initiatives of the early 1970s. These demonstration projects employed social workers to arrange for and coordinate services for high-need groups such as the mentally ill and frail elderly, for example.
During the 1980s, several types of case managers were documented in the healthcare literature, yet few in traditional settings such as hospitals were familiar with these programs. On the acute care side, the New England Medical Center in Boston was one of the first to implement a nursing model of case management that emphasized coordination of care and services within the hospital environment and beyond. As cost containment methods began to bear down upon the healthcare environment, other organizations throughout the country began to implement case management programs to better manage the needs of target groups.
During the late 1980s, a large private health care system in San Diego implemented an acute care, ICU, and women's care case management model based upon the New England model of case management. The author of this course was involved in the development and implementation of the hospital's models, as well as the eventual change to bedside care management model at a later time. Such hospital models sought to not only better manage complex clients, but to also promote the professionalism of the nursing staff.
On the heels of successful acute care and community health models of case management, insurance companies and specialized treatment facilities increasingly used nurses and other healthcare roles as case managers. It was not uncommon to see social workers, occupational therapists, rehab counselor and other similar roles in case management roles in certain agencies.
During the 1990s there was growth in "external" case management roles or independent case managers who specialize in the delivery of services over the entire continuum of illness or injury. Independent case managers often work with clients who do not easily fit within the confines of other case management services, such as long-term care or acute care programs. For example, some independent case managers specialize in catastrophic pediatric cases and follow the child's care throughout a long period, from acute setting to home care.
This similar model is used with adults who have suffered injuries or catastrophic Illness such as cancer or AIDS and are in need of long-term planning and care facilitation. Quite often the independent case manager has been a registered nurse who had an extensive intensive care or oncology background that could rely upon years of experience and well-developed network in beginning a case management practice.
Also during the 1990s, there was continued growth in case management services Within public and private school systems in the U.S. These nurses were assigned with not Only school wellness programs, health screening, and day to day needs, they were also Focusing more and more on the needs of the family and community in healthcare needs.
Where are Case Managers Found Today?
Case Managers are now found in multiple settings and provide varied se appropriate to the needs of the clients in that setting. Today, case managers can be found in:
Essentially, case managers may be found anywhere there are significant client needs that require the specialized services that only case managers can provide in navigating the complex healthcare systems. These specialized services are based upon the case management process.
Role Conflict in the Past Decade
During the late 1980s and early 1990s, many healthcare organizations, in response to the effects of managed care, focused more on utilization management than case management. With spiraling healthcare costs and diminishing revenues and reimbursement, hospitals were particularly challenged to focus on patient length of stay, early discharge, and management of costs. During these years, those in community or home care agencies, and others in non-acute settings, felt that the acute care case managers were simply utilization reviewers.
This role disparity continued throughout the late 1990s and caused dissension among some of the professional case management organizations and those in professional roles. It is still not uncommon to find case/care managers in hospital settings whose primary role is cost containment, rather than patient advocacy and quality care.
What is the Case Management Process Now?
The case management process in its entirety involves six steps as shown in Table 2, not unlike the nursing process. The primary difference from the nursing process is the depth and breadth of the case management process in client, family, community needs and goals.
Assessment
The first step in the process is to assess the need for intervention by the case manager through gathering data and critical, objective evaluation of relevant data (CMSA). This assessment takes into consideration not only the physical, psychosocial, or environmental needs of the client, but also the spiritual, financial, vocational needs, learning capability, functional health and self care ability, and other related assessment.
Problem Identification
The case manager uses the objective data gathered during careful assessment to identify potential for effective interventions. The case manager selects a case load that reflects the most likelihood that client outcomes can be positively influenced. This step is an essential screening phase of the process that assists the case manager in identifying appropriate opportunities for intervention. Such screening may uncover or identify issues such as: (CMSA)
The Case Manager also identifies patterns that may lead a client to a case management program, and those clients who would benefit from early intervention.
Planning
The case management plan identifies immediate, short term, and ongoing client needs as well as how these needs can most appropriately be met. Goals and time frames for achieving goals are included in the hr plan. The client and family, as appropriate, must agree to the plan. The case manager assures that appropriate benefits or funding are available to implement the plan. The case manager demonstrates an understanding of cost-containment strategies for the client (and agency) that are irrespective of the limitations of the insurance benefits available to the client. In other words, case managers do not recommend plans of care that the client is unwilling, or unable to take part in, or that would bankrupt the client in the course of therapy.
Monitoring
The case manager maintains communication with the client, family, and care providers so that important information regarding services provided and the effect on identified goals can be disclosed. The case manager employs a method of checking, regulating and documenting the quality of care, and services and products delivered to the client, to determine if the goals of the care plan are being accomplished or if those goals need to be revised. This monitoring is a key element in ongoing quality monitoring.
If the case manager identifies problems or major variances in this phase, he or she is obligated to document this data and make necessary revisions or referrals to revise the plan of care.
Evaluating
The case manager measures the client's response to the healthcare services delivered. This also involves measuring the effectiveness, necessity, and efficacy of the care plan itself. The quality of the services and products from providers is also measured. This evaluation involves a comprehensive and independent assessment of the client's status and progress toward reaching the goals set forth in the care plan. If the case manager finds that the outcome of the care is anticipated to be terminal, the case manger focuses efforts on maintaining the stability of the environment of the client and family.
If the evaluation shows that the patient has regressed or not moved forward on care goals, the case manager should find out reasons for this outcome and encourage appropriate adjustments in the care plan, the services, or providers to improve the outcomes. In some cases, particularly for clients with major physical or mental needs, the case manager cannot work alone on this and must consult with appropriate professionals to help the patient or family deal with issues that have affected care providers work or the home environment. In today's complex healthcare needs, it is wise to know ahead of time that can be consulted or referred to for patient's unexpected needs.
Outcomes
Case management is by nature a goal-directed process intended to improve patient's outcomes. The case manager identifies and coordinates changes in practice patterns and treatment plans to bring about appropriate care and cost-effective outcomes. The case manager plans with the client and family to reach a goal-oriented care process That analyzes and gives direction to a treatment plan that moves the client toward health, wellness, or adaptation.
Measurement of care outcomes against predefined and bench-marked measures is a necessity in healthcare. In some settings, case managers are not involved in client outcome measurement and thus have no method to report, evaluate, and improve services. While many hospitals, home care agencies, and other care settings are addressing outcome measurement, outcome measurement should be an agenda item and goal for all case management services.
Benefits of Case Management to Clients
Multiple client populations can benefit from the services case manager provide. Case management is appropriate for both those with acute illness as well as those with a chronic condition. Case management is never mandated but is always provided with the client's consent. The case manager serves as client advocate and incorporates the client's individual needs and goals throughout the case management process.
The Client Benefits from:
In Addition, the Case Manager Advocates for the Client By:
What are Clinical Practice Guidelines?
Clinical practice guidelines are evidence-based recommendations for healthcare providers and practitioners to use when making healthcare decisions for clients. To be evidence-based, these guidelines must be based upon current research findings that have been graded (evaluated) for scientific strength (Sexton, 1999).
Guidelines furnish case managers with current scientific evidence and professional consensus information to guide care given by healthcare providers. Specifically, guidelines are necessary to more effectively arrange, coordinate, and monitor care given (Sexton). Many consider clinical guidelines akin to a well-articulated road map for care. For all healthcare providers, guidelines suggest the best strategies for prescribing the most appropriate treatment for a given clinical condition.
Guidelines can serve multiple purposes: professional and patient education; reducing variations in practice; provide milestones for clinical management; and lead to well-articulated disease-specific standards of care (Sexton). Clinical pathway tools are institution-specific plans for organizing and sequencing the delivery of care by the multidisciplinary team, for a specific surgical or medical diagnosis, and may not be based upon strong scientific evidence. Rather, some pathways are based on agency trends and physician preferences.
Why have Guidelines been Developed?
Until recently, it was common for practice trends to be guided by expert opinion and general consensus of various health care providers and experts. During the 1990s, the Agency for health Care Policy and Research (AHCPR) adopted and published a successful guideline development process that promoted scientific evidence and formal analytic methods to be used as a basis for practice recommendations. With this scientific process as the framework, the AHCPR has become the primary federal agency actively in producing and publishing evidence-based clinical practice guidelines. Their web site is listed at the end of this chapter.
By late 1998, the AHCPR supported twelve new Evidence-Based Practice Centers (EBPCs) who undertake scientific analysis and evidence synthesis to create reports and technology assessments on the prevention, diagnosis, treatment, and management of common diseases and clinical conditions (Sexton). These evidence reports provide a solid foundation for organizations and specialty groups to use in developing practice guidelines and other clinical tools to continuously improve patient care.
Who Uses Practice Guidelines?
Nurses and case managers can expect to be involved in practice guidelines in the near future, if not already using these tools. Clinical practice guidelines are becoming widely accepted by the medical community as appropriate tools for use by physicians, nurse, therapists, and consumers in making health care decisions. It is important that nurses, physicians, and other professionals understand the difference between practice guidelines and pathways, as the two are not to be used interchangeably, as previously discussed.
What are Case Management Guidelines?
Similar to clinical practice guidelines, case managers have guidelines developed by professional organizations and specialty groups, to serve as the basis for professional case management practice. The CMSA has guidelines for patient care in case management roles.
In addition to case management guidelines, professionals in managed care nursing also have standards of practice. The managed care standards regarding the nursing process is similar to the case management process standards with the exception of the addition of "research educational resources" after client data is collected and before the development of the plan of care (American Association of Managed Care Nurses, 1998).
As the future of healthcare rolls out, case management professionals will be challenged not only by direct changes in the healthcare environment, but also by trends And predictions documented by the American Hospital Association in its Future scan 2000 report (American Hospital Association, 2000).
The Future scan 2000 is a report that provides new insights into the near and farther future. Based on the results of a survey of 400 healthcare executives, strategists, marketers and communicators, the report shows that many topics are rushing toward us, and major providers are bracing themselves for the hard times ahead. The ports discuss Medicare payment issues, staffing shortages, and many other important topics that case managers must be prepared for to practice in the very near future. While this text will go over the hot issues, nurses and case managers can become updated on healthcare topics that will bring challenges and many solid positive outlooks ahead. This is said because the experts felt that the long-term outlook for healthcare is "fundamentally sound."
There are five major categories in the Future scan report. Within these five areas are the top 1 0 trends:
| Trends in Society | 1.1 Aging of the Baby Boomers will be one of the most important factors during the future of healthcare.
1.2 Internet-empowered consumes will be much more informed about medicine, healthcare choices, and technology. |
| Science & Technology | 2.1 Biomedical technology innovations will infuse healthcare.
2.2 Electronic medical records will become widespread in hospitals. |
| Economics & Finance | 3.1 Bankruptcies of hospitals and medical groups will increase. 3.2 Healthcare's share of the Gross Domestic Product could grow to 1 7 percent. |
| Health Policy | 4.1 Medicare and Medicaid HMOs will grow more slowly in the next three years. 4.2 Medicare reform to add pharmacy benefit will be a major election issue. |
| Healthcare Organizations | 5.1 Staffing shortages will increase despite higher wages And bonuses. 5.2 Complementary medicine will be offered by more Mainstream providers
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The following chapters present and discuss the issues with current references that support and expand upon the topics. The discussion and critical review of significant trends in U.S. healthcare also presents important implications for case management practice as we greet the future rushing toward us.
The following are suggested resources and Web sites for case management guideline Information, best practices, and related information.
Case Management Society of America (CMSA) http://www.cmsa.org
American Association of Managed Care Nurses (AAMCN) http://www.aamcn.org
National Institutes of Health (NIH) http://www.nih.gov
United States Department of Health and Human Services (HHS)
http://www .os.dhhs.gov
Agency for Health Care Policy and Research (AHCPR) http://www.ahcpr.gov
Commission on Accreditation for Rehabilitation Facilities (CARF)http://www.carf.org
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) http://www. icaho.org
National Committee for Quality Assurance (NCQA) http://www.ncqa.org
References
Table 1.Specialized Skills for Effective Case Management
|
Source: Compiled from Information in Reference 1
The Case Management Process |
Assessment Case Identification & Selection |
Problem Identification |
Planning |
Monitoring |
Evaluation |
Outcomes |
Table 2 The Case Management Process. Compiled from Reference1.