Since the late 1980s and the 1990s, a variety of case management programs have emerged (Huber, 2002). From 1990 to 2005, case management evolved rapidly in response to changes in the health care environment and increased managed care programs. Client service use reflects a greater emphasis on health care costs; therefore third-party payers evaluate the appropriate use of health care resources such as diagnostic tests, laboratory tests, length of hospital visits, and duration of home health care services. Managed care organizations (MCOs) may deny reimbursement to health care providers that exceed the expected costs. Health care providers must closely monitor their use of resources; therefore they introduced various forms of case management programs.

The development of case management models in acute hospital and community settings created confusion over what programs and services compose case management and how case management differs from other services such as social services and discharge planning. A single definition of case management does not exist. The Case Management Society of America (CMSA) (2002) offers the following definition of case management:

The philosophy statement published by CMSA (2005) states:

According to the American Nurses Association, nursing case management is “a health care delivery process whose goals are to provide quality health care, decrease fragmentation, enhance the client’s quality of life, and contain costs” (1992).

Many labels describe case management within a profession. In addition to case management, other titles include case coordination, care management, geriatric care management (GCM), integrated care management, continuing care coordination, continuity coordination, and service coordination. Multiple case management labels cause further confusion among health care professionals and health care consumers. Case management takes on many forms depending on the level, discipline, organization, situation, and basic client care needs that are addressed (White and Hall, 2006).

Some hospitals, health maintenance organizations (HMOs), and other insurance companies inaccurately use the term case management to describe “utilization management,” “managed care,” or the method of monitoring and controlling service use within a system or care episode to control cost. Many of these providers have case management programs that transcend use control and monitor the patient following hospital discharge. Some of the programs provide continued services to high-risk clients for an indefinite time, regardless of the client’s location (Box 9-1).

Case management programs aim to provide a service delivery approach to ensure the following: cost-effective care, alternatives to institutionalization, access to care, coordinated services, and patient’s improved functional capacity (Lyon, 1993). These goals apply to community health and acute care settings.

Case management has a long history with the mentally ill, elderly patients, and the community setting (Steinberg and Carter, 1983). Public health, mental health, and long-term care settings have implemented and studied case management services and have reported them in their literature for many years (Mahn and Spross, 1996; Weil and Karls, 1985).

Case management is used to promote and integrate the coordination of clinical services, linking patients to community services and agencies. Case managers monitor resources used by clients, support collaborative practice and continuity of care, and enhance patient satisfaction (Yamamoto and Lucey, 2005).

For hospitalized patients, health care service coordination begins either upon the patient’s admission or shortly thereafter and continues following the patient’s discharge for an unspecified time. The patient’s physical and psychosocial status and the plan’s success will determine the length of the case manager’s evaluation and intervention (Lyon, 1993; Lyon et al., 1995)

Numerous trends influenced case management programs. During the 1970s, hospitals billed Medicare, Medicaid, and other third-party payers for client services and received reimbursement. Health care costs skyrocketed and rapidly became the basis for discussion and concern throughout the health care industry and the country. In 1983, PL 98-21 of the Social Security Amendments introduced the prospective payment system (PPS) in the acute care setting. Under the PPS, health care providers receive a fixed amount of money based on the relative cost of resources they use to treat Medicare patients within each diagnosis-related group. Other third-party payers followed this example and negotiated reimbursement schedules through preferred provider programs or managed care contracts (U.S. Department of Commerce, 1990).

Health care costs continue to escalate, the population is aging, and the elderly population is increasing. Many elderly suffer from chronic illness and require health care resources. These issues influenced, and still influence, the introduction of case management services to control costs and distribute health care resources in a variety of settings.

It is essential to determine what classification of health care provider is best qualified to provide case management services. Traditionally, case managers were social workers (SWs) who assumed the role of discharge planner. Client health care needs have become more complex, the need for ongoing patient assessment has emerged, and available resources have become more numerous and diverse; therefore nurses have become case managers. Several health care organizations exclusively employ SWs in case manager roles, others exclusively employ nurses in case management, and others use a combination of SWs and nurses, depending on the client population’s needs. Combining the strength and knowledge of the nurse’s clinical background with the SW’s community service background is a combination that can efficiently move a client through the complex health care system (Lyon et al., 1995).