This module aims to provide an overview of the history of case management and the current role that nurse case managers provide to patients in different healthcare settings.
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Disclosure Statement
This module aims to provide an overview of the history of case management and the current role that nurse case managers provide to patients in different healthcare settings.
Upon completion of this course, the learner should 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 the case manager
- 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, 2022a) defines chronic diseases as conditions that last more than 1 year and require ongoing medical attention and/or limit activities of daily living. Chronic disease is the leading cause of death and disability in the US. An estimated 6 out of 10 adults in the US 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) significantly contribute to the annual $3.8 trillion spent on US health care. The current life expectancy for adults in the US is 78.8 years (CDC, 2022b; Dirkes & Kozlowski, 2019; Stark, 2020).
The Centers for Medicare and Medicaid Services (CMS) have estimated that acute care hospital costs are approximately 32% of all healthcare 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. Although this subset of patients accounts for 2% of total hospitalizations, it is estimated that they utilize 14% of all hospital days and cost more than $20 billion annually. 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 healthcare organizations have utilized case managers to achieve the goals set forth by the ACA (Armold, 2019; Healthcare.gov, n.d.; Stark, 2020).
Case Management
Case management is a collaborative effort between the patient, the family, and other 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 involved healthcare team members 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., multimorbidity, HIV/AIDS, or cancer patients). The nurse collaborates with other medical professionals to create and implement a long-term care plan that ensures patients get the comprehensive 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, starting with diagnosis and following through until resolution (Case Management Society of America [CMSA], n.d.; Giardino, 2021).
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 describes a program composed of a broad set of activities or tasks that include health-related aspects of case management. However, care management extends to various services, supports, and benefits across many domains, including recreational activities, healthy lifestyle programs, and social enrichment programs with a benefit plan. Care coordination also includes activities included in 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, often by determining certain groups who should receive case management services. Disease management is a narrow form of case management, where services are directed at a particular patient group with a common disease or condition. Case management is a fundamental element of care management, care coordination, and disease management (Giardino, 2021).
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, including the patient, their family support system, the healthcare 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 while ensuring that time and cost are considered to benefit 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.).
History of Case Management
Case management 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 noted, as well as resources provided and documentation outlining anticipated future assistance needs. 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; Joo & Huber, 2018; Joo & Liu, 2021).
The 1980s saw increased use of case management in acute care facilities where it had previously not been utilized. CMS funded five projects (i.e., care clinic, school-based health center, community nursing center, 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 c
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are 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 brought utilization of the case management role to 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; 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 Case Management Society of America (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 helps to ensure that the case manager has the knowledge, skills, and competencies to provide safe and quality case management to patients and families. To become certified, CCMC requires a license or certification as an RN, rehabilitation counselor, disability management specialist, social worker, or a Baccalaureate or 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). 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 healthcare professionals (HCPs; CCMC, n.d.). 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 ongoing training and education of case managers
- using background information for accreditation and credentialing activities (CCMC, n.d.)
The National Committee for Quality Assurance (NCQA, n.d.) is a governing body that provides certification and accreditation for many healthcare 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 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 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, 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 healthcare needs in collaboration with their provider, family, and other members of the patient's healthcare 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.; Giardino, 2021). 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.; Giardino, 2021)
These phases may be revisited as necessary until achieving the desired outcome(s). The process may also 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, centering on a patient and the patient's support system. In the same way, case management is adaptable and individualized to the practice setting, facility, and patient (CCMC, n.d.; Giardino, 2021).
Screening
Screening includes investigating pertinent information as it applies to the individual's health status 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 (CCMC, n.d.; Giardino, 2021). 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, n.d.; Giardino, 2021)
Assessment
Assessment includes gathering data regarding the patient's situation similar to those reviewed during screening but more in-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 and utilization of prior services
- physical, emotional, and cognitive functioning
- psychosocial network and support system
- health engagement
- self-care knowledge and ability
- readiness for change (CCMC, n.d.; Giardino, 2021)
The case manager has three primary objectives while assessing the patient/support system:
- identifying the patient's priority 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, n.d.; Giardino, 2021)
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.; Giardino, 2021).
Stratification of Risk
The case manager seeks to confirm or update the patient's risk category based on the information gathered. Stratification assesses the needed intervention level 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, stratification may be done by an automated system before a case manager formally assesses the patient. Regardless of automation assistance, the case manager is ultimately responsible for this step. They should review the information generated, clarify, and follow up if appropriate (CCMC, n.d.; Giardino, 2021).
Planning
The care planning step involves creating a care plan that defines treatment goals, tasks and activities needed to meet those goals, and 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.; Giardino, 2021).
Implementation
CCMC (n.d.) 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 resources needed for the patient to reach the desired outcome. The case manager is a liaison between the patient, their support system or caregivers, their providers, and their payer source or insurance company. 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 coordination 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 (CCMC, n.d.; Giardino, 2021).
Follow-up
The follow-up process involves evaluating the case management plan and progress towards 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 to facilitate positive outcomes are made at this point in the process. 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 family/support system to assist them in understanding 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.; Giardino, 2021).
Transitioning
The transition phase is particularly vital, including transferring to home or another healthcare facility. During the transition phase, errors and miscommunications are most likely to occur. The case manager can minimize these issues through post-transition 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, or other needed services and equipment, ensuring a smooth transition to home. For patients not transitioning to home, case managers can complete the referral process to a long-term care (LTC) or rehabilitation facility (CCMC, n.d.; Giardino, 2021).
Communication and Evaluation Post-Transition
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 follow-up is an additional point where concerns or issues can be addressed, and follow-ups are made to ensure satisfaction. The case manager will then assess 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 these factors are used to determine the effect on the patient's condition (CCMC, n.d.; Giardino, 2021).
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, although it is advisable and highly encouraged that nurses seek and obtain certification. While most nurses obtain the skills they need 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 (MS) or doctoral degree. The American Nurses Credentialing Center's (ANCC) 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 the eligibility requirements to take the certification examination and successfully passed the exam, 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) 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 (CCMC, n.d.).
Areas of Practice
Case managers work in various healthcare 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. According to the CCMC, certified case managers work in a variety of settings, including insurance companies (28.8%), hospitals (22.8%), workers' compensation (11.6%), and independent organizations (e.g., home health services or private insurers; 7.3%). The CCMC conducts a national survey every five years to collect data on current case management practices. The 2019 survey revealed that the case manager role is increasing in professional diversity. The number of certified case managers has increased from 37,000 to 48,000 over the last five years. Although the number of nurses fulfilling case management roles continues to grow, the overall percentage of nurses 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 increase in the number of younger case managers, with nearly 16% younger than 40 (Armold, 2019; Baker & Kurland, 2020).
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 reducing readmissions. However, there is still confusion among 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 of disease management as their education and licensure do not support this area (Giardino, 2021).
Conclusion
The role of the case manager is in high demand as the care coordinator in a rapidly changing healthcare 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 and include nursing, social work, and counseling. As the healthcare landscape and practice areas change, so has case management. Case managers can practice independently in a variety of facilities or via telehealth. No matter where the engagement occurs, positive outcomes are still the goal through education, health promotion, risk prevention, and quality individualized care.
References
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Baker, M., & Kurland, M. (2020). Case management demographics reveal insights into who is practicing case management today. Professional Case Management, 25(3), 176-178. https://doi.org/10.1097/NCM.0000000000000435
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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