This module provides an overview of the history of case management and the current role that nurse case managers play across various health care settings.
Course preview
Nurse Case Management
Disclosure Statement
This module provides an overview of the history of case management and the current role that nurse case managers play across various health care settings.
Upon completion of this course, learners will be able to:
- explore the history of case management
- define the role of the case manager and the philosophy behind the role
- discuss education and certification qualifications for case managers
- describe the steps of the care management process
Nurses are responsible for offering high-quality, evidence-based care to optimize patient outcomes. As new treatments emerge, people are living longer, healthier lives. As the US population ages, more people live with chronic health conditions. The Centers for Disease Control and Prevention (CDC, 2024a) defines chronic diseases as conditions that persist for more than 1 year and that require ongoing medical attention and/or limit daily activities. Chronic disease is the leading cause of death and disability in the United States. An estimated 6 out of 10 adults in the United States have at least one chronic disease, and 4 out of 10 adults have two or more chronic diseases. Chronic conditions such as heart disease, cancer, chronic lung diseases, diabetes mellitus (DM), Alzheimer’s disease, and chronic kidney disease (CKD) contribute significantly to the annual $4.5 trillion spent on US health care. The current life expectancy for adults in the United States is 78.4 years, and the worldwide population of adults over the age of 65 is expected to double by 2025 (Case Management Society of America [CMSA], 2024; CDC, 2024a, 2024b, 2025; Stark, 2020).
The Centers for Medicare and Medicaid Services (CMS, 2023) have estimated that acute care hospital costs are approximately 31% of all health care dollars spent. In 1983, CMS instituted the prospective payment reimbursement system (PPRS) to reduce the length of stay (LOS) and spending. The PPRS led to the creation of diagnosis-related groups (DRGs), which established fixed payments for hospitals based on a diagnosis. When a patient remains in the hospital past the established DRG period, the hospital does not receive reimbursement for those services. Despite these efforts, some patients have extended hospitalizations, particularly those with complex chronic diseases. Patients with extended hospitalizations are at higher risk for morbidity and mortality. Patients with complex chronic conditions are often frequent users of health care services. Although this subset of patients accounts for only 10% of the population, it is estimated that they account for up to 70% of health care expenditures. In 2010, the comprehensive health care reform law, known as the Affordable Care Act (ACA), was enacted. The ACA has three primary goals: making affordable health insurance available, expanding the Medicaid program to cover more people, and supporting innovative medical delivery to lower health care costs. Many health care organizations have utilized case managers to achieve the goals set by the ACA (CMSA, 2024; CMS, 2024; Healthcare.gov, n.d.; Stark, 2020).
Case Management
Case management is a collaborative effort between the patient, the family, and all disciplines and resources involved in patient care. It begins with a comprehensive assessment of needs and available resources. Planning for the nurse case manager is based on the nursing process. Through planning and evaluation, the nurse will collaborate with all health care team members involved to ensure that the patient’s and family’s needs are being met efficiently and cost-effectively. The focus is on quality of care and patient safety. Case management is outcome-driven and can be achieved through care coordination or complex care management. A registered nurse (RN) in the case management role coordinates all aspects of care for individual patients. The case management nurse often works with specific groups of patients requiring ongoing medical care (i.e., patients with multimorbidities, HIV/AIDS, or cancer). The nurse collaborates with other medical professionals to create and implement comprehensive long-term care (LTC) plans that ensure patients receive the care they need. Case managers can develop long-lasting relationships with patients while helping them navigate through the complexities of chronic disease management. Complex case management can often encompass the entire treatment course, spanning from diagnosis to resolution (CMSA, n.d., 2024; Giardino & De Jesus, 2023).
The term case management can be confused with other similar terms, including care management, care coordination, and disease management. Although these terms overlap in their definition, there are some differences. Care management encompasses a wide range of activities and tasks related to the health aspects of case management. However, care management encompasses a range of services, supports, and benefits across various domains, including recreational activities, healthy lifestyle programs, and social enrichment programs, all of which are supported by a benefit plan. Care coordination also encompasses activities that are integral to case management. However, care coordination is associated with a broader context, such as population health, where organizations can utilize various strategies to manage the needs of a population of patients and identify certain groups who should receive case management services. Disease management is a specialized form of case management that focuses on providing services to a specific patient group with a common disease or condition. Case management is a fundamental element of care management, care coordination, and disease management (CMSA, n.d., 2024; Giardino & De Jesus, 2023).
The Philosophy of Case Management
The philosophy of case management focuses on helping patients reach their optimal level of wellness and capability. When this is achieved, the benefits are experienced by all involved, including the patient, their family support system, the health care team, and insurance providers. The cornerstone of case management is patient autonomy. Autonomy is achieved by the patient when the case manager acts as an advocate, providing quality communication, education, and resources and facilitating services. Case managers coordinate care and identify appropriate providers and facilities, ensuring that time and cost are considered to benefit both the patient and the reimbursement agencies. The optimal climate for successful case management includes collaborative communication with all parties involved in the patient’s care (CMSA, n.d., 2024).
History of Case Management
Case man
...purchase below to continue the course
agement is not a new discipline; it began with public health nursing and incorporates practice techniques from the social work and behavioral health professions. Records dating back to the 1860s have described case management services in the tenement houses of newly arrived immigrants. Much like today’s case management practice, individual and family needs were identified, resources were provided, and documentation outlining anticipated future assistance needs was maintained. In the 1930s, case management processes were utilized by visiting nurses. As it is recognized today, case management began as American service members returned from World War II in 1945. The war produced an abundance of severely wounded service members with complex medical needs requiring care coordination and resources to return to an optimum quality of life. The 1960s introduced the official term “case management” with the advent of community-based nursing and social work projects (Armold, 2019; Giardino & De Jesus, 2023; Joo & Huber, 2018; Joo & Liu, 2021).
The 1980s witnessed an increase in the use of case management in acute care facilities, where it had previously been underutilized. CMS funded five projects (i.e., care clinics, school-based health centers, community nursing centers, university community health services, and a large health corporation) that utilized RNs as case managers to coordinate care for Medicare beneficiaries. These projects demonstrated a benefit to the process and outcomes of care. Before 1983, health care reimbursement was based on the fee-for-service (FFS) model, which disincentivized providers to reduce health care costs. This model led to the overuse and misuse of health care resources, particularly in the acute care setting. This decade also saw the utilization of the case management role by health insurance companies in preferred provider organizations (PPOs), health maintenance organizations (HMOs), and workers’ compensation programs. During this time, capitation (the payment to providers determined by the number of patients) intensified, creating a specific niche for case management. These factors paved the way for case management to move into the acute care setting (Armold, 2019; Giardino & De Jesus, 2023; Joo & Huber, 2018; Joo & Liu, 2021).
As the role of case management expanded, the need for legitimacy as a profession and a definition of standards became evident. As a result, in 1990, the CMSA was launched. This organization helped develop standards of care for practicing case managers, including nurses and other disciplines, such as social workers. The ability to obtain certification was realized in 1993 through the Commission for Case Manager Certification (CCMC). Certification through the CCMC ensures that the case manager possesses the necessary knowledge, skills, and competencies to deliver safe and high-quality case management to patients and their families. To become certified, CCMC requires a license or certification as an RN, rehabilitation counselor, disability management specialist, social worker, or a baccalaureate or a master’s degree in health or human services. CCMC also requires 2 years of experience as a case manager or 1 year of experience as a case manager with supervision by a certified case manager (Armold, 2019; CCMC, n.d.-a; Giardino & De Jesus, 2023; Joo & Huber, 2018; Joo & Liu, 2021). In addition to certification, the CCMC has created a case management framework and body of knowledge (CMBOK). The CMBOK is a comprehensive, peer-reviewed body of online knowledge for case managers and other health care professionals (HCPs; CCMC, n.d.-b). The case management framework can be used for the following:
- enhancing the structure and outcome of case management programs in various care settings
- guiding professional development and advancement of case managers
- effectively designing roles, responsibilities, and competencies for case managers
- using credible professional care management standards and practices
- demonstrating the value of case management programs
- developing academic programs for case management
- assisting in the ongoing training and education of case managers
- using background information for accreditation and credentialing activities (CCMC, n.d.-b)
The National Committee for Quality Assurance (NCQA, n.d.) is a governing body that provides certification and accreditation for many health care entities. It assesses providers using a specific dashboard known as the Healthcare Effectiveness Data and Information Set (HEDIS). This dashboard is the most widely used performance measurement tool in health care. The NCQA also assists consumers and employers in making informed choices about health care by sharing information publicly on the organization’s website. NCQA Case Management Accreditation evaluates organizations that perform case management services, typically focusing on patients at high risk of experiencing costly hospitalizations or poor health outcomes due to complex social, behavioral, or medical needs. Organizations must meet program criteria to pursue accreditation (NCQA, n.d.). The NCQA Case Management Accreditation provides a framework for implementing evidence-based practices to ensure cost-effective and efficient case management delivery and includes:
- managing patients as they move between care settings
- using patient-centered assessments to determine care needs
- developing personalized care plans
- providing access to qualified case management staff
- protecting patients’ personal health information
- monitoring care goal progress (NCQA, n.d.)
The Role of a Case Manager
Case management aims to meet the individual’s health care needs in collaboration with their provider, family, and other members of the patient’s health care team. Case managers utilize communication and the nursing process framework to assess individual and family needs and coordinate available resources. The “Triple Aim” of the case manager is to improve the care experience, facilitate a healthier population, and reduce the societal cost of care. Effective communication is imperative to health promotion and risk reduction (CCMC, n.d.-b; Giardino & De Jesus, 2023). There are nine fluid steps that case managers utilize when planning and managing care for their patients:
- screening
- assessing
- stratifying risk
- planning
- implementing (care coordination)
- following up
- transitioning (transitional care)
- communicating post transition
- evaluating (CCMC, n.d.-b; Giardino & De Jesus, 2023)
These phases may be revisited as necessary until the desired outcome(s) are achieved. The process is flexible and may be affected by the patient’s care setting, the characteristics of the patient’s support system, and the practice setting of the case manager. The case management process is holistic and centered on the patient and their support system. Similarly, case management is adaptable and individualized to the specific practice setting, facility, and patient (CCMC, n.d.-b; Giardino & De Jesus, 2023).
Screening
Screening involves examining pertinent information related to the individual’s health status to identify specific patient needs. The primary objective is to identify services that may benefit the patient. Early intervention is a tangible benefit of screening, thereby increasing the chances of success in achieving patient goals (CCMC, n.d.-b; Giardino & De Jesus, 2023). Critical information about the patient/support system gathered during screening may include the following (to the extent available):
- risk stratification category or class
- health services utilization
- claims data
- past and current health condition
- socioeconomic and financial status
- home environment
- health insurance coverage
- prior services
- psychosocial network and support system
- physical, emotional, and cognitive functioning
- self-care ability (CCMC, n.d.-b; Giardino & De Jesus, 2023)
Assessment
Assessment includes gathering data regarding the patient’s situation, similar to that reviewed during screening, but in more depth. The information collected about the patient/support system may include:
- past and current health conditions
- socioeconomic and financial status
- service utilization
- health insurance plan benefits and coverage
- availability and utilization of prior services
- home condition and safety
- physical, emotional, and cognitive functioning
- health engagement
- psychosocial network and support system
- self-care knowledge and ability
- readiness for change (CCMC, n.d.-b; Giardino & De Jesus, 2023)
The case manager has three primary objectives while assessing the patient/support system:
- identifying the patient’s priority problems to be addressed, along with individual needs and interests
- determining the expected care goals and target outcomes
- working with the patient to develop a plan of care to address mutually agreed upon goals and outcomes that address the identified issues (CCMC, n.d.-b; Giardino & De Jesus, 2023)
The case manager may further apply two key strategies for effective information gathering. First, using standardized assessment tools, and checklists, information is attained in person or via telephone conversations and interviews with the patient, their support systems, and other professionals involved in the patient’s care. Second, pertinent information may be obtained through a comprehensive or focused chart review of the patient’s available medical records (CCMC, n.d.-b; Giardino & De Jesus, 2023).
Stratification of Risk
The case manager seeks to confirm or update the patient’s risk category based on the information gathered. Stratification assesses the necessary level of intervention by determining where the patient falls on a spectrum of low to high risk. Additional assessments, such as a biomedical screening, can further focus on the level of need based on the presence of risk factors. In some organizations, stratification may be done by an automated system before a case manager formally assesses the patient. Regardless of the assistance provided by automation, the case manager is ultimately responsible for this step. They should review the generated information, clarify any points, and follow up if necessary (CCMC, n.d.-b; Giardino & De Jesus, 2023).
Planning
The care planning step involves creating a care plan that defines treatment goals, outlines the tasks and activities needed to meet those goals, and identifies the access to services and support systems required to achieve those goals. Next, the case manager should identify target outcomes specific to the patient. Then, the case manager actively navigates or guides the patient to services and supports, recognizing and removing anticipated or unexpected barriers (CCMC, n.d.-b; Giardino & De Jesus, 2023).
Implementation
CCMC (n.d.-b) defines implementation as executing specific case management activities or interventions to accomplish the goals outlined in the case management plan. At this point, the case manager should coordinate care by organizing, confirming, integrating, and adjusting the necessary resources to help the patient achieve the desired outcome. The case manager serves as a liaison between the patient, their support system or caregivers, HCPs, and their payer source or insurance company. During the implementation phase, the organization and coordination of care occur through the allocation of personnel and other resources necessary to perform and complete patient care activities. Care coordination involves collaboration among team members to access the necessary resources for the patient and their family. The RN case manager most frequently performs this coordination as they are in the best position to take the lead to ensure that the plan of care is executed, costs are managed, resources and services are not duplicated, and the discharge plan is resolved (CCMC, n.d.-b; Giardino & De Jesus, 2023).
Follow-up
The follow-up process involves evaluating the case management plan and progress made toward the desired outcomes. This evaluation is accomplished by communicating with the patient, caregiver, provider, and other relevant sources. Recommendations for changes to the plan of care are made at this point in the process to facilitate positive outcomes. The follow-up or evaluation process should be at specific milestones to determine if the patient is meeting their target goals or outcomes. The case manager should educate the patient and their family or support system to help them understand relevant health topics. During this phase, the case manager can also identify services or accommodations the patient may need and help navigate the barriers to utilizing these services (CCMC, n.d.-b; Giardino & De Jesus, 2023).
Transitioning
The transition phase is particularly vital, including transferring to home or another health care facility. During the transition phase, errors and miscommunications are most likely to occur. The case manager can minimize these issues through posttransition care and follow-up education. Care coordination ensures continuity of care between facilities or agencies through good communication. Case managers also secure durable medical equipment (DME), home health services, or other necessary services and equipment, ensuring a smooth transition to home. For patients not transitioning to home, case managers can complete the referral process to an LTC facility or a rehabilitation facility (CCMC, n.d.-b; Giardino & De Jesus, 2023).
Communication and Evaluation Post Transition
After an episode of care, the case manager will follow up with the patient or caregiver to assess progress. This posttransition communication is crucial. Medication management, self-care ability, compliance with follow-up appointments, and satisfaction with home health or outpatient therapies are areas of concern and evaluation. This follow-up is an additional opportunity to address concerns or issues and ensure satisfaction through further follow-ups. The case manager will then assess the effectiveness of the case management plan of care during the final evaluation. The areas of focus may include financial aspects, standard expected outcomes, risk-benefit analysis, quality of life, patient and family satisfaction, understanding the plan of care, and the patient’s or family’s ability to execute their responsibilities. All these factors are used to determine the effect on the patient’s condition (CCMC, n.d.-b; Giardino & De Jesus, 2023).
Education and Certification for Nurse Case Managers
Case managers must hold at least an Associate Degree (AS), with a preference for a Bachelor of Science (BS) degree in nursing. Certification is not required, but it is advisable and highly recommended for nurses to seek and obtain certification. While most nurses acquire the skills they need through on-the-job training, the current trend is toward more facilities, such as insurance companies and hospitals, requiring certification. Some case managers may hold a Master of Science (MS) or a doctoral degree. The American Nurses Credentialing Center’s (ANCC, n.d.) Nursing Case Management Board certification examination is a competency-based assessment that provides a valid and reliable evaluation of the entry-level clinical knowledge and skills of RNs in the nursing case management specialty following initial licensure as an RN. Once the candidate has met the eligibility requirements to take the certification examination and successfully passed it, they are awarded the Nursing Case Management certification (CMGT-BC) credential. This credential is valid for five years (ANCC, n.d.). The American Case Management Association (ACMA, n.d.) also offers the Accredited Case Management Credential, and the CCMC offers Certified Case Manager credentialing. Eligibility may require a mixture of education, clinical experience, and on-the-job training (ACMA, n.d.; CCMC, n.d.-b).
Areas of Practice
Case managers work in various health care settings, including hospitals, LTC facilities, insurance companies, home health agencies, and private practices. Case managers interested in even more professional autonomy can become independent case management consultants. The CCMC conducts a national survey every few years to collect data on current case management practices. The survey revealed that the case manager role is becoming increasingly diverse in terms of profession. The three most important roles of a case manager were identified as ensuring appropriate care, advocating for patient, and educating and empowering them to make informed decisions. Of the survey respondents, 52% work remotely, 30% work on-site, and 18% work in a hybrid arrangement. The number of certified case managers has increased to over 50,000. Although the number of nurses fulfilling case management roles continues to grow, the overall percentage of nurse case managers has decreased as other professions have begun to fulfill the role, including social workers, vocational rehabilitators, counselors, psychologists, and disability managers. The CCMC survey also revealed an aging case manager workforce, 82% of whom were over the age of 40 and only 2% under the age of 30 (CCMC, 2023; Morley & Gillingham, 2025).
Case Management and Social Work
As health care has changed over time, so has the role of case management. Case management departments have assumed the responsibility of ensuring safe discharge planning and reducing readmissions. However, there is still confusion among the general public and some health care members regarding the differences between an RN case manager and a social work case manager. Notably, the social worker will often handle discharge planning and social support; their role in case management does not include the clinical aspect of disease management, as their education and licensure do not support this area (Giardino & De Jesus, 2023).
Conclusion
The role of the case manager is in high demand as the care coordinator in a rapidly changing health care landscape. There are infinite areas where the case manager can work to facilitate personalized, quality, cost-effective, and individualized care. The roles in case management are as varied as the areas of practice, including nursing, social work, and counseling. As the health care landscape and practice areas evolve, so does case management. Case managers can practice independently in various facilities or via telehealth. Regardless of the setting, the goal remains one of achieving positive outcomes through education, health promotion, risk prevention, and quality, individualized care (Giardino & De Jesus, 2023).
References
American Case Management Association. (n.d.). ACM certification exam. Retrieved June 16, 2025, from https://www.acmaweb.org/acm
American Nurses Credentialing Center. (n.d.). Nursing Case Management certification (CMGT-BC). Retrieved June 16, 2025, from https://www.nursingworld.org/our-certifications/nursing-case-management
Armold, S. (2019). Case management: An overview for nurses. Nursing 2022, 49(9), 43–45. https://doi.org/10.1097/01.NURSE.0000577708.49429.83
Case Management Society of America. (n.d.). What is a case manager? Retrieved June 15, 2025, from https://www.cmsa.org/who-we-are/what-is-a-case-manager
Case Management Society of America. (2024). The impact of case management on the healthcare system. https://cmsa.org/the-impact-of-case-management-on-the-healthcare-system-3
Centers for Disease Control and Prevention. (2024a). About chronic diseases. https://www.cdc.gov/chronic-disease/about
Centers for Disease Control and Prevention. (2024b). Living with a chronic condition. https://www.cdc.gov/chronic-disease/living-with/index.html
Centers for Disease Control and Prevention. (2025). Deaths and mortality. National Center for Health Statistics. https://www.cdc.gov/nchs/fastats/deaths.htm
Centers for Medicare and Medicaid Services. (2023). National health expenditures 2023 highlights. https://www.cms.gov/files/document/highlights.pdf
Centers for Medicare and Medicaid Services. (2024). Prospective payment systems—General information. https://www.cms.gov/medicare/payment/prospective-payment-systems
Commission for Case Manager Certification. (n.d.-a). CCM eligibility at a glance. Retrieved June 16, 2025, from https://ccmcertification.org/get-certified/certification/ccmr-eligibility-glance#
Commission for Case Manager Certification. (n.d.-b). Introduction to the case management body of knowledge. Retrieved June 16, 2025, from https://cmbodyofknowledge.com/content/introduction-case-management-body-knowledge
Commission for Case Manager Certification. (2023). Survey findings: Many board-certified case managers work remotely as salaries continue to climb. https://ccmcertification.org/press-releases/survey-findings-many-board-certified-case-managers-work-remotely-salaries-continue
Giardino, A. P., & De Jesus, O. (2023). Case management. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK562214
Healthcare.gov. (n.d.). Affordable Care Act (ACA). US Centers for Medicare and Medicaid Services. Retrieved June 15, 2025, from https://www.healthcare.gov/glossary/affordable-care-act
Joo, J. Y., & Huber, D. L. (2018). Scoping review of nursing case management in the United States. Clinical Nursing Research, 27(8), 1002–1016. https://doi.org/10.1177/1054773817717861
Joo, J. Y., & Liu, M. F. (2021). Understanding nurse-led case management in patients with chronic illnesses: A realist review. Western Journal of Nursing Research, 43(2), 182–195. https://doi.org/10.1177/0193945920943827
Morley, C., & Gillingham, D. C. (2025). The case management aging workforce: Preparing for the future of the profession. CMSAtoday. https://cmsatoday.com/2025/06/02/the-case-management-aging-workforce-preparing-for-the-future-of-the-profession
National Committee for Quality Assurance. (n.d.). Case management accreditation. Retrieved June 16, 2025, from https://www.ncqa.org/programs/health-plans/case-management-cm
Stark, P. (2020). Advancing complex case management competencies in a health care system. Professional Case Management, 25(1), 19–25. https://doi.org/10.1097/NCM.0000000000000361
Powered by Froala Editor