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., geriatrics, HIV/AIDS, or cancer patients). The nurse collaborates with other medical professionals to create and implement a long-term care plan that ensures the patient gets the comprehensive care they need. Case managers have the opportunity to develop long-lasting relationships with patients. Complex case management can often encompass the entire treatment course, starting with diagnosis and following through to resolution (RegisteredNursing.org, 2017).
Case management: Case management is a collaborative effort between the patient, the family, and other disciplines and resources involved in the care of the patient. 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 involved members of the healthcare team to ensure that the patient’s and family’s needs are being met in the most efficient and cost-effective way possible. The focus is on quality of care and patient safety. Case management is outcome-driven and can be achieved either through care coordination or complex care management (Case Management Society of America [CMSA], 2017).
National Committee for Quality Assurance: The National Committee for Quality Assurance (NCQA, n.d.) is a governing body that provides certification and accreditation for a multitude of healthcare entities. It assesses providers using a specific dashboard known as the Healthcare Effectiveness Data and Information Set (HEDIS). This is the most widely used performance measurement tool in health care. The NCQA also assists consumers and employers in making informed choices about healthcare by sharing information publicly on the organization’s website. “NCQA Case Management Accreditation evaluates organizations performing case management services that typically focus on patients who are at high-risk of experiencing costly hospitalizations or poor health outcomes because of complex social, behavioral, or medical needs. Organizations must meet program criteria to pursue accreditation” (NCQA.org, n.d., para. 10).
Case management is not a new discipline; it began with public health nursing and incorporated practice techniques from the social work and behavioral health professions. There are records dating back to the 1860s, which reference services in the tenement houses of newly arrived immigrants. Much like today’s case management practice, individual and family needs were noted as well as resources received and documentation anticipating future assistance (Cesta, 2017).
Case management, as it is recognized today, began as American service members were returning from the war in 1945. World War II produced an abundance of severely wounded servicemen with complex medical needs that required coordination of care and resources to return to an optimum quality of life. The 1960s brought on the official term “case management” with the advent of community-based nursing and social work projects. (MilitaryCME, n.d.).
The 1980s saw increased use of case management in acute care facilities where it had previously not been utilized. Signing on early to this process was the New England Medical Center in Boston. The decade also brought utilization of the case management role to health insurance companies in the areas of Preferred Provider Organizations, Health Maintenance Organizations, and workers’ compensation programs. At this time, capitation (the payment to providers determined by the number of patients) intensified, creating a specific niche for case management (MilitaryCME, n.d.).
As the role of case management expanded, the need for legitimacy as a profession and a definition of standards became evident. In 1990 the Case Management Society of America (CMSA) was launched. This allowed for standards of care to be developed by practicing case managers that included nurses as well as other disciplines such as social workers. The ability to obtain certification was realized in 1993 through the Commission for Case Manager Certification (CCMC) (MilitaryCME, n.d.).
The Philosophy of Case Management
Ultimately the philosophy of case management is concerned with the patient reaching their optimal level of wellness and capability. When this is achieved, the benefits are felt by all involved: the patient, their family support system, the healthcare team, and insurance providers as a whole. 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, resources, and facilitating services. Case managers coordinate care, identify appropriate providers and facilities while ensuring that time and cost are considered to the benefit of both the patient and the reimbursers. The optimal climate for successful case management includes collaborative communication with all parties involved in the patient’s care (CMSA, 2017).
The Role of a Case Manager
The goal of case management is to work towards meeting the healthcare needs of the individual in collaboration with the patient’s provider, the patient, and other members of the patient’s healthcare team. Case managers utilize communication and the nursing process framework to assess the individual and family needs and to coordinate available resources. The “Triple Aim” of the case manager is to improve the experience of care, facilitate a healthier population, and reduce the societal cost of care. Good communication is imperative to achieve health promotion and risk reduction (CCMC, 2015).
There are nine fluid steps that case managers utilize when planning and managing care for their patients:
- Stratification of risk
- Implementing (care coordination)
- Transitioning (transitional care)
- Communication post-transition
- Evaluation (CCMC, 2015)
These phases may be revisited as necessary until the achievement of the desired outcome(s). The process may also be affected by the care-setting of the patient, characteristics of the patient’s support system, and the practice setting of the case manager (CCMC, 2015).
The case management process is holistic in its approach to management, centering on a patient and the patient’s support system. In the same way the practice of case management is adaptable and individualized to the practice setting and facility, case management is individualized to the patient (CCMC, 2015).
Screening includes the investigation of pertinent information as it applies to the individual’s health status in order to identify specific patient needs. The main objective is to determine services that might benefit the patient. Early intervention is a tangible benefit of screening, thereby increasing the chances of success in achieving patient goals. Critical information about the patient/support system gathered during screening may include the following (to the extent available):
- Risk stratification category or class
- Claims data
- Health services utilization
- Past and current health condition
- Socioeconomic and financial status
- Health insurance coverage
- Home environment
- Prior services
- Physical, emotional, and cognitive functioning
- Psychosocial network and support system
- Self-care ability (CCMC, 2015)
Assessment includes gathering data regarding the patient's situation similar to those reviewed during screening but to a greater depth. The information collected about the patient/support system may include:
- Past and current health conditions
- Service utilization
- Socioeconomic and financial status
- Health insurance plan benefits and coverage
- Home condition and safety
- Availability of prior services
- Physical, emotional, and cognitive functioning
- Psychosocial network and support system
- Health engagement
- Self-care knowledge and ability
- Readiness for change (CCMC, 2015)
The case manager has three primary objectives while assessing the patient/support system:
- Identifying the patient's key problems to be addressed, as well as 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, 2015)
The case manager may further apply two key strategies for effective information gathering. Using standardized assessment tools and checklists, information is either attained in person or via telephone conversations and interviews with the patient, their support systems, and other professionals involved in the patient’s care. In addition, pertinent information may be obtained through comprehensive or focused chart review of the patient’s available medical record(s) (CCMC, 2015).
The case manager seeks to confirm or update the patient’s risk category based on the information gathered (CCMC, 2015). Stratification assesses the needed level of intervention by determining where the patient ranks from low- to high-risk. Additional assessments, such as a biomedical screening, can further focus the level of need based on the presence of risk factors. In some organizations, this stratification may be done by an automated system before the patient is formally assessed by case management. The case manager is ultimately responsible for this step, regardless of automation assistance. They should review the information generated and clarify/follow-up if appropriate (Carmen, 2015).
CCMC (2015) defines implementation as “the process of executing specific case management activities or interventions that will lead to accomplishing the goals outlined in the case management plan.” At this point, the case manager should coordinate care by organizing, confirming, integrating, and adjusting the resources needed for the patient to reach the desired outcome. The case manager “acts as a liaison between the patient, their support system or caregivers, their providers, and their payer/insurance company” (Carmen, 2015, para. 10).
During the implementation phase, the organization or coordination of care occurs with the appropriation of personnel and other resources needed to perform and complete necessary patient care activities. Care coordination is the collaboration among team members to acquire the appropriate resources for the patient and family. This is most frequently performed by the RN case manager, 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 (Cesta, 2018).
The follow-up process involves evaluation of the case management plan and progression towards desired outcomes. This is accomplished by communicating with the patient, caregiver, provider, and any other relevant sources. Recommendations for changes to the plan of care to facilitate positive outcomes are made at this point in the process (Carmen, 2015).
The transition phase is particularly vital, as it includes transferring to home or another facility; this is where errors and miscommunications are most likely to occur. The case manager has the ability to minimize these issues through education regarding post-transition care and follow-up. Care coordination ensures continuity of care between facilities or agencies through good communication. Case managers also secure durable medical equipment (DME), home health, or other needed services and equipment, ensuring a smooth transition to home (Carmen, 2015).
After an episode of care, the case manager will follow-up with the patient or caregiver to determine how things are progressing. This communication post-transition 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 is an additional point where concerns or issues can be addressed and follow-ups are made to ensure satisfaction (Carmen, 2015).
The case manager assesses the effectiveness of the case management plan of care during the final evaluation. The areas of focus may be financial, standard expected outcomes, risk-benefit analysis, quality of life, patient and family satisfaction, understanding the plan of care, and the ability of the patient or the family to execute their responsibilities. All of these factors are used to determine the effect on the patient’s condition (Carmen, 2015).
Education and Certification
Case managers must hold at least an Associate Degree in Nursing with a preference for a Bachelor of Science in Nursing degree. Certification is not required, although it is advisable and highly encouraged that nurses seek out and obtain certification. While most nurses obtain the skills they require through on-the-job training, the current trend is towards more facilities such as insurance companies and hospitals requiring certification. Some case managers may hold a Master of Science in Nursing or doctorate degrees (Nurse Journal, 2019).
The American Nurses Credentialing Center’s (ANCC, n.d.) “Nursing Case Management board certification examination is a competency-based examination that provides a valid and reliable assessment of the entry-level clinical knowledge and skills of registered nurses in the nursing case management specialty after initial RN licensure. Once the candidate has completed eligibility requirements to take the certification examination and successfully passed the exam, they are awarded the credential: Registered Nurse-Board Certified (RN-BC). This credential is valid for five years” (ANCC, n.d., para. 1).
Additionally, the American Case Management Association offers the Accredited Case Management Credential, and the CCMC offers Certified Case Manager credentialing. Eligibility may require some mixture of education, clinical experience, and on-the-job training (RegisteredNursing.org, 2017).
Areas of Practice
Case managers work in a number of varied settings throughout healthcare; these can include but are not limited to hospitals, nursing homes, insurance companies, hospice, and private practices. Case managers who are interested in having even more professional autonomy can become independent case management consultants (RegisteredNursing.org, 2017).
Case Management and Social Work
As healthcare has changed over time, so has the role of case management. Case management departments have taken on the responsibility of safe discharge planning and the reduction of re-admissions. There is still confusion with the general public and some healthcare 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 as their education and licensure do not support this area (Christie, 2018).
The role of the case manager is in high demand as the coordinator of care in a rapidly changing landscape of healthcare. 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 and include nursing, social work, and counseling. As the healthcare landscape and practice areas change, so has it for case management. Case managers can practice independently in a variety of facilities or via telehealth. No matter where the engagement takes place, positive outcomes are still the goal through education, health promotion, risk prevention, and quality individualized care (Bogue, 2019).
American Nurses Credentialing Center. (n.d.). Nursing Case Management certification (RN-BC). Retrieved November 2019 from https://www.nursingworld.org/our-certifications/nursing-case-management/
Bogue, A (2019). Three reasons why you should pursue a career in case management. Retrieved from https://www.medixteam.com/blog/3-reasons-pursue-career-case-management/
Carmen, A. (2015). Case management process and tools. Retrieved from https://casemanagementstudyguide.com/ccm-knowledge-domains/case-management-concepts/case-management-process-and-tools/
Case Management Society of America. (2017). What is a case manager? Retrieved from https://www.cmsa.org/who-we-are/what-is-a-case-manager/
Cesta, T. (2017). What’s old is new again: The history of case management. (2017). Retrieved from https://www.reliasmedia.com/articles/141367-whats-old-is-new-again-the-history-of-case-management
Cesta, T. (2018). Coordination of care and the role of the case manager. Retrieved from https://www.reliasmedia.com/articles/142793-coordination-of-care-and-the-role-of-the-case-manager
Christie, E (2018). Optimizing the differences between RN case managers and social workers. Retrieved from https://www.reliasmedia.com/articles/142788-optimizing-the-differences-between-rn-casemanagers-and-social-workers
Commission for Case Manager Certification (2015). CCMC’s case management body of knowledge. Retrieved from https://www.cmbodyofknowledge.com/
MilitaryCME (n.d.). Care management through military and civilian case management models. Retrieved October 2019 from https://militarycme.com/feature-articles/care-management-through-military-and-civilian casemanagement-models-636
National Committee for Quality Assurance. (n.d.). About the National Committee for Quality Assurance. Retrieved October 2019 from https://blog.ncqa.org/about-ncqa/
Nurse Journal (2019). RN case manager salary and job outlook. Retrieved from https://nursejournal.org/nursing-case-management/rn-case-manager-salary-and-job-outlook/
RegisteredNursing.org. (2017). Nurse case manager. Retrieved from https://www.registerednursing.org/specialty/case-management-nurse/