Case and Population Health Management

Case and Population Health Management

Diane L. Huber


It appears that we are in the midst of a care delivery revolution: the radical shift from an acute care–based delivery system to one founded on primary care as the major setting for the delivery of health services. Along with shifts to Patient-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs) and reimbursement shifts triggered by the Patient Protection and Affordable Care Act (ACA) of 2010 have come a renewed emphasis on, and reimbursement incentives for, care coordination, integration, and prevention strategies. This is the age of care coordination.

The modern era of case, disease, and population health management began in the early 1990s. The effectiveness of what was called case management (CM) in producing quality and cost containment outcomes began to be noticed anecdotally by providers in the field, but more importantly by health insurance companies who came to believe it worked. However, case management services were rarely paid for outside of rehabilitation and some social services areas, which severely limited the widespread implementation of CM and inhibited care integration. Despite funding restrictions, the belief in the effectiveness of CM spurred research and the development of the knowledge base and evidence for practice. Major professional, certification, and trade associations also grew over the last 20 to 25 years.

The field first split into CM and disease management (DM) (Huber, 2005a). With the criticism that not all health conditions are “diseases,” such as behavioral health, the term disease management was dropped in favor of population health management (PHM). Rigorous research and federal government funded demonstration grants continued to solidify the evidence base for practice.

When needed services other than acute care are actually added to/provided for in the mix of health care, it is difficult to demonstrate cost savings. However, CM, DM, and PHM strategies all have proven positive clinical outcomes. What is clear is that care coordination is the core element common to all provider interventions in CM, DM, and PHM.


Central to accomplishing the “triple aim” of better care, better health and lower costs is the strategy called care coordination. Care coordination was defined by the Agency for Healthcare Research and Quality (AHRQ, 2007, p. v) as “the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities, and is often managed by the exchange of information among participants responsible for different aspects of care.”

According to AHRQ (2007, p. vi), “Care coordination interventions represent a wide range of approaches at the service delivery and systems level. Their effectiveness is most likely dependent upon appropriate matching between intervention and care coordination problems, though more conceptual, empirical and experimental research is required to explore this hypothesis.”

Care coordination seeks to meet patient needs and deliver high-quality care (AHRQ, 2011a). Its goal is high-quality transitions and referrals to meet the Institutes of Medicine’s (IOM) six aims of safe, effective, efficient, timely, equitable, and patient- and family-centered care (Improving Chronic Illness Care, 2012). According to the IOM’s report entitled Crossing the Quality Chasm: A New Health System for the 21st Century, the U.S. health care system should use the six criteria to ensure that quality care is provided (IOM, 2001). Transitions of care focus on reducing re-hospitalization rates and enhancing post-discharge care, according to the Centers for Medicare & Medicaid Services (CMS) and the IOM (AHRQ, 2011b). The definition of transition of care is “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location” (AHRQ, 2011b, p. 1). Transitions of care have become more imperative than ever before in current health care reform.


The Case Management Society of America (CMSA) is the professional organization representing case managers in practice. It is a multidisciplinary organization. The CMSA (2012a, p. 1) defines case management as “a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.” Thus there is a major professional organization that defines case management as a multidisciplinary provider intervention and promotes the knowledge base for practice.

In nursing, the American Nurses Association (ANA) first defined nursing case management as a system of health assessment, planning, service procurement, service delivery, service coordination, and monitoring through which the multiple service needs of clients are met (ANA, 1988; Zander, 1990). Hospital acute care nursing case management is an attempt to reconfigure the delivery of hospital care away from previous care models. Disciplines other than nursing, such as social work, have discipline-specific definitions of case management. In addition, there is a consumer definition of case management, that case managers work with people to get the health care and other community services they need, when they need them, and for the best value, that was promulgated as a communication tool to help explain CM to the public.


Case management (CM) is an intervention strategy used by multiple health care providers and systems to advocate for clients, coordinate health care delivery, and facilitate outcomes of both cost and quality. Arising out of pressures for cost containment, and later valued for quality control in the midst of alarming medical errors, CM came to be seen by health plans, and later hospitals, as a major solution to serious problems of mission and margin.

Case management as a nursing model of care evolved in the late 1980s. It has been defined as both a process (it is a provider intervention) and a care delivery model. CM has developed as a method to manage care. Managed care is care coordination that is organized to achieve specific client outcomes, given fiscal and other resource constraints. Managed care has been described as “the systematic integration and coordination of the financing and delivery of health care” (Grimaldi, 1996, p. 6).

Case management and care coordination have been the care delivery models used for years by public health and community health nurses (Mikulencak, 1993). In these settings, CM has been centered on the needs of the client rather than the shift, unit, or system. Because it is an intervention used by many providers and in multiple settings, as management can occur inside or outside the hospital only, extend across the health care continuum, or be linked to a population focus.

Case management is a system of client care delivery that focuses on the achievement of client outcomes within effective and appropriate time frames and resources. CM has components of health services delivery, coordination, and monitoring, all of which are used to meet the multiple service needs of clients. Hospital-based acute care nursing CM was focused on an entire episode of illness, crossing all settings in which the client receives care. Care is directed by a case manager, who is not always a nurse, and can be unit- or population-focused.

Case management is an interdisciplinary provider intervention that crosses settings and sites of care. Previously used as a strategy in social services, rehabilitation, and public health, by the 1990s CM was a popular way to address coordination of care for the ill and the poor and to manage catastrophic injury or illness. Case managers were deployed to decrease fragmentation, reduce expense by streamlining care, and control costs by linking, advocating, coordinating, negotiating, educating, and monitoring. As CM became more popular, case managers’ employment settings shifted to hospitals.

Registered nurses (RNs) have emerged as the large majority of case managers, especially in hospitals, in part because of their specialized expertise for the function of determining medical necessity for health care payment and because of care coordination for complex medical discharge planning needs (Park et al., 2009; Zander, 2002). Zander (2002) called CM “the nursing process applied at a system level” (p. 58). This is because CM services by nurses are designed to produce a balance between the demands of the mission (quality health care) and the operational margin (costs and resources). Case management has grown in conjunction with the experience of risk by payers and providers (Zander, 2002). The American Nurses Association (ANA, 2012) has issued a position statement on care coordination and the RN role to recognize and promote RNs’ integral role in the care coordination process.

Case management has garnered considerable attention in health care. It has been suggested that the processes associated with CM have the potential to save money, improve effectiveness, and maintain or improve the quality of care (Lu et al., 2008). However, a diversity of CM approaches exists. For example, “case management may describe a patient care delivery system, a professional practice model, a group of activities that a nurse performs within an organizational setting, or a separate service provided by private practitioners” (Goodwin, 1994, p. 29). The term case management can be specific to an institution, refer to services rendered to a population or community, or be a separate service provided by independent case managers or health insurance companies (Goodwin, 1994). Models have been implemented in many settings, including acute care, long-term care, and community health care (Huber, 2005a; Zander, 2002). Case management is a central component of integrating and coordinating care across the health care continuum. It is focused on the individual recipient of services.

Case management is an approach to managing care and service delivery that is designed to coordinate care, decrease costs, and promote access to appropriate and needed services. Case management has a heritage more than a century old, but it gained wide implementation and popularity as systems of managed health care emerged in the 1990s. Managed health care, more simply called managed care, has gained momentum and evolved as a response to national concern over rising health care costs and expenditures, increasing care fragmentation, and lack of continuity and access under fee-for-service reimbursement. By the end of the 1990s, health maintenance organizations (HMOs) had become the most predominant form of health care coverage among U.S. businesses with more than 100 employees (Coleman, 1999; Tahan, 1998).

Internal and external pressures on the health care delivery system have been intensifying, including a shortage of RNs and the aging of baby boomers. A convergence of cost, quality, and access demands has created a complex and volatile environment. Complexity arises from the simultaneous balancing of needs for quality, productivity, and flexibility. Health care providers are directed to manage both clinical care outcomes and associated resources by providing cost-efficient and cost-effective health care services and being accountable for the value of services relative to the costs of those services. Specifically, the pressure on nurses is to balance quality of care with client advocacy. Thus nurses need to demonstrate and document the effect of nursing care on client outcomes and on the efficiency and price competitiveness of provided services. The benefits achieved need to exceed the costs incurred. The mounting pressures on the health care delivery system since the mid-1980s have provided an impetus for the explosive growth of case management as both an economically important strategy for controlling costs and an opportunity for health care services improvement during economic hard times.

Like health care, CM as a professional practice role is in transition. For example, the Case Management Society of America (CMSA, 2012b), the organization representing case managers, was founded in 1990. Since then it has grown to an international nonprofit organization dedicated to the support and development of the profession of case management. It has over 75 chapters and more than 11,000 individual members. It has promulgated the following:

Case Management

Multiple disciplines lay claim to CM. Case management is a term that refers to client-focused strategies concentrating on the coordination and integration of health services for clients with complex or costly health problems. CM has a strong interdisciplinary component. There have been a variety of definitions of CM, often reflecting the perspective of a specific discipline and creating confusion. As the professional organization representing case managers, CMSA’s definition is used by convention.

Despite the variety of definitions, the general meaning of CM is any method of linking, managing, or organizing services to meet client needs. Thus CM entails the coordination and sequencing of care. It helps tighten the plan of care and link direct caregivers and services across facility and service boundaries.

Acute care hospital nursing CM is a system in which the accountability for the care management of clients in a specific diagnosis-related group DRG category, disease group, or other population over an entire hospitalization is assigned to an RN. The nurse case manager coordinates care across the continuum of services. Hospital nursing CM usually is targeted at high-risk, high-volume, and/or high-cost populations. Although all clients need to have their care coordinated, CM functions best to coordinate health care services for high-risk populations across community, acute, and long-term care settings (Simpson, 1993). Zander (1991) defined CM as a matrix model at the clinician-provider level in acute care.

Case management in acute care nursing is an attempt to reconfigure the delivery of hospital care into a more integrated system management care modality. CM and care coordination have been the care delivery modalities employed by public health and community health nurses (Mikulencak, 1993). In these settings, CM has been centered on client needs rather than being shift- or unit-centered. CM can occur in the hospital only, extend across the health care continuum, or be linked to a population.

CM is described as a system of client care delivery that focuses on the achievement of client outcomes within effective and appropriate time frames and resources. It is a system of health services delivery, coordination, and monitoring through which multiple service needs of clients are met. CM operates at the intersection of organizational systems and the delivery of clinical care. It is focused on an entire chronic or catastrophic condition or conditions, crossing all settings in which the client receives care. New services across the continuum of health care are incorporated as needed. Care is directed by a case manager, often a nurse, and focuses on an interdisciplinary team effort.

A term related to CM is disease management,  which is defined as a comprehensive, integrated approach to care and reimbursement based on a disease’s natural course. Disease management programs contain a series of clinical processes and services across the health care continuum that rely on informatics to identify and manage a medical or chronic condition in a particular at-risk population to improve care, promote wellness, and manage or reduce costs (Ward & Rieve, 1997). Such disease state CM programs are population-based approaches to the identification and management of chronic conditions. Health status is assessed, plans of care are developed, and data are collected to evaluate the effectiveness of the program (Levitt et al., 1998). These programs are focused on the group level of aggregation and may be community-focused or population health–focused.

Critical Pathways

A critical pathway is a written plan that identifies key, critical, or predictable incidents that must occur at set times to achieve client outcomes within an appropriate time frame, such as a length of stay in a hospital setting. A critical pathway has been defined as an “outline or diagram that documents the process of diagnoses or treatment deemed appropriate for a condition based on practice guidelines” (MediLexicon, 2012, p. 1). Critical pathways are tools used to help providers identify, measure, and analyze care processes and desired patient outcomes (Renholm et al., 2002). As a pathway, they are a tracking system for the timing of treatments and interventions, health outcomes, complications, activity, and teaching/learning. They detail essential care steps and describe the expected progress. They include time-dependent functions and organize and integrate provider interventions in a multidisciplinary format and across multiple settings or levels of care (Cesta & Tahan, 2003).

Providing an overview of the whole process, critical pathways are best practice tools that identify and document the standardized, interdisciplinary processes that need to occur for a patient to move toward a desired outcome in a defined period of time. Elements include all providers’ assessments and interventions, laboratory and other diagnostic tests, treatments, consultations, activity level, patient and family education, discharge planning, and desired outcomes (Renholm et al., 2002). Critical pathways have been described as protocols of interdisciplinary treatments, based on professional standards of practice and placed in order on a decision tree (Simpson, 1993).

Critical pathways are called by a variety of names, such as critical path, coordinated care path, clinical pathway, clinical protocol, care track, care step, or evidence-based practice protocols. They are case management tools that map out the plan of care and guide and document care within a framework that reflects the research, experience, and consensus priorities of a multidisciplinary group of providers actively engaged in providing care to the target population. Critical pathways are cause-and-effect visual grids or paths to direct care toward goals. They show key incidents and expected behaviors. Critical pathway elements include an index of problems, a timeline, a variance record, and the path or grid. Critical pathways are one form of structured care methodologies (SCMs), or streamlined interdisciplinary tools, used to “identify best practices, facilitate standardization of care, and provide a mechanism for variance tracking, quality enhancement, outcomes measurement, and outcomes research” (Cole & Houston, 1999, p. 53). Examples of SCMs are critical pathways, evidenced-based algorithms, protocols, standards of care, order sets, and clinical practice guidelines. The use of best evidence is considered the gold standard to reduce practice variation in an environment focused on patient outcomes. Critical paths outline time and the sequence of events for an episode-of-care delivery. Resources appropriate in amount and sequence to a specific case type and individual client are managed for length of stay, critical events and timing, and anticipated outcomes. Variances are noted and analyzed. The process of developing and using critical paths encourages both critical thinking and accountability. Critical paths can be used to educate, prepare, and orient care providers and to negotiate expectations and care roles with clients. Critical paths can and should be individualized to each client. They are major tools of outcomes management and coordination of care delivery.

Critical pathways display expected outcomes. A difference between what was expected and what actually occurred is called a variance. A variance is a deviation from a standard. Variances can be either positive or negative. Sources of variance include client- and family-related, systems-related, or provider-related factors. A process needs to be in place to document, collect, and analyze variances for trends and opportunities for cost reduction and quality improvement (Cesta & Tahan, 2003). A literature review revealed that the use of critical pathways has a positive impact on patient care outcomes (Renholm et al., 2002).

Benchmarking and evidence-based practice are used in constructing and evaluating critical pathways. Benchmarks form a frame of reference against which an institution can compare itself relative to others. Benchmarking is a useful strategy for helping to understand internal processes and performance levels. Benchmarks help identify performance gaps. Consensus benchmarks can be established by professional societies, health systems, national databases, or texts and manuals (Cesta & Tahan, 2003).


Case Management Models

A variety of case management models have arisen; some are nursing models, and others are non-nursing models. The core elements center around a case manager who coordinates and monitors the care given to clients by multiple health care providers and services in an attempt to decrease service fragmentation and improve the quality of care (Rheaume et al., 1994). Weil and Karls (1985) identified eight main service components common to all case management models (Box 12-1).

CM exists in many contexts and settings, including insurance-based programs, employer-based programs, workers’ compensation programs, social services programs, independent CM practice, for-profit CM companies, medical practice, nursing practice, public health nursing and home health care agencies, maternal-child settings, and mental health settings.

CM programs incorporate assessment and problem identification; planning; procurement, delivery, and coordination of services; and monitoring to ensure that the multiple services needs of the client are met. These are clinical systems that focus on the achievement of client outcomes, within effective and appropriate time frames and resources, or the entire episode of illness, crossing all settings in which the client receives care. The case manager’s role is as a practitioner who actively coordinates the client’s care. CM is by definition a process. It expands on components of the nursing process to respond to the needs of clients along the care continuum and across multiple settings.

Using patient-focused strategies to coordinate care, CM becomes a system or design for moving a recipient through the health care system. A model of CM will be designed for a large, rather generic target group or population (e.g., hospitalized, long-term care, chronic care, rehabilitation) or for a specified “expanse” on the health care continuum (e.g., an episode in one setting, in one organization, or for the whole continuum). A model of CM will specify the standards for care and resource use, relationships, and responsibilities in a more general sense. The nurse may or may not be a direct care provider.

Several organizing frameworks or methods of classification have been considered in grouping CM models. Because of the variability in how CM programs are set up, classification into model types helps describe and better compare them. The following are common ways of describing CM models:

Using these distinctions, CM models can be understood in terms of perspective (e.g., organization or providers), scope (e.g., services inside an organization), and time (e.g., one episode or across time and settings).

In the literature, many types of CM models and labels are found. There are multiple discipline–related models and one generally accepted overarching general model. Two factors are common across all CM models: the core component is coordination of care, and the core principle is advocacy. In addition to coordination of care, advocacy, brokering of services, and resource management, there are fairly common process elements in CM models regardless of the specific discipline. These models are typically tailored to fit unique target groups, vulnerable populations, settings, or other factors found in the discipline.

Nursing and health care models tend to focus on the management of health/illness or disease or the rehabilitation needs of an individual or population. These models are sometimes called medical models, medical-social models, acute care nursing CM models, or disease management models. In the nursing literature, there has been some confusion about whether CM is a care delivery model or an intervention that entails a process. In both nursing and social work, there is a differentiation between CM designed to deliver services and CM designed to coordinate the provision of services (Ridgely & Willenbring, 1992).

There are two basic CM models that were identified in the nursing literature: the New England Medical Center model of acute care nursing case management and the community-based model of Carondelet St. Mary’s.

The New England Medical Center model is an extension of primary nursing methodology called nursing CM and is focused on the acute care hospital episode (Zander, 1990, 1991, 1992, 2002). This model exemplifies organization-specific models; it is hospital-based CM. It is best known for structuring the episode of care. In the mid-1980s, this model was introduced at the New England Medical Center, using principles of planning and concurrent management from engineering and other fields to extend primary nursing into outcomes management. The goal was to balance cost, process, and outcomes. The New England Medical Center model is a client-centered approach instituted during episodes of acute illness. It focuses on outcomes, resource utilization, and nursing accountability (Clark, 1996). Written, standardized documents such as case management plans, timelines, and critical paths were developed and evolved into CareMap® tools that formed the basis for a comprehensive hospital case management system at the New England Medical Center. The complete CareMap® system includes the following:

The New England Medical Center model defined CM as a care delivery model called nursing CM.

Carondelet St. Mary’s Community Nursing Network, or the Arizona Model (Forbes, 1999), used professional nurse case managers (bachelor’s and master’s level), organized as a nursing HMO, at the hub of a network to broker services. This model type is known as a beyond-the-walls, medical-social, across-the-continuum of care model. It is best known for its innovative work in moving beyond the episode of care and into the continuum. This hospital-to-community model used case managers to follow the movement of high-risk clients from acute care to community to long-term care settings. Case managers are responsible for clients with chronic health problems, and the relationship is long-term (Clark, 1996).

There are four models in social work: brokerage, primary therapist, interdisciplinary team, and comprehensive. Social casework emphasizes the development of new resources, linkages to existing service agencies, coordination of care, advocacy, and teaching. Casework typically includes increasing the individual’s self-reliance and independence, as well as coordinating and integrating care (Ridgely & Willenbring, 1992). The emphasis is on vulnerable populations.

The brokerage model emphasizes the case manager’s traditional linkage function. Clients are linked to a network of providers and service coverage using assessment and referral and ensuring the availability of service activities (Raiff & Shore, 1993). The brokerage approach is sometimes described as a generalist approach. The case manager is a professional responsible for an individual client or a set of clients. The generalist carries out all CM functions and provides the basic direct service, coordination, and advocacy necessary in all CM programs (Weil & Karls, 1985). The primary goal is to increase the likelihood that clients will receive the right services, in proper sequence, and in a timely fashion. To achieve this, the case manager plans a comprehensive service package and negotiates through barriers that prevent clients from accessing needed services. Cost savings may or may not be an explicit goal, but such savings may be expected because the case manager facilitates better access to cost-effective alternatives, achieves better coordination and less duplication of services across agencies, reduces utilization of more expensive and less effective sites of care or services, and diverts clients from admissions (Ridgely & Willenbring, 1992).

In the primary therapist model, the case manager’s relationship to the client is primarily therapeutic, and CM functions are undertaken as a part of, or an extension of, therapeutic intervention. The client has one person to relate to about treatment, service access, and case coordination. However, the therapist may feel that CM is a secondary activity to therapeutic work (Weil & Karls, 1985).

The interdisciplinary team model uses a specialized interdisciplinary team in which each member has a specific responsibility for service activities in his or her area of expertise. In combination, the activities of these specialized case managers constitute a complete CM process. The team might divide responsibilities by activity, such as intake, service linkage, and case monitoring (Weil & Karls, 1985). Team structures vary considerably. In some, all case managers on the team are interchangeable and serve the total group of clients. Other programs consist of multidisciplinary teams in which each professional provides specific services to the clients assigned to the team. In other cases, individual case managers carry individual caseloads but provide backup assistance to each other. Despite being called “teams,” the specific configuration actually may be critical to the program’s success (Ridgely & Willenbring, 1992).

The comprehensive service center model is used in service centers that provide comprehensive services, including social and emotional support, vocational training, and residential facilities. This type of program is often rehabilitative (Weil & Karls, 1985) and is seen in areas such as developmental disabilities and long-term physical disabilities. A personal strengths model may be used to help clients focus on and achieve goals (Huber, 2005a).

Other models of CM in health care include independent practice or private case management. Private CM covers those services contracted for by individuals or families or those subcontracted for by other groups. This approach arose because of the concern over rising health care costs and the confusion that accompanies the choices consumers must make. The case manager has three main functions: coordination, advocacy, and counseling (Clark, 1996). Some examples include entrepreneurial or small independent case managers and practices in for-profit, large, national CM companies.

Long-term care, rehabilitation, occupational health, workers’ compensation, pharmacy, and medical case management models exist. Many medical models fall within disease management programs.

Insurance models include brokerage, gatekeeper, catastrophic, HMO types, and governmental models. The brokerage model within insurance companies includes an emphasis on linkage with no provision of direct services. It is similar to the broker in other social work models except for a strong emphasis on conserving benefits utilization.

Gatekeeper (managed care) models manage access to services and promote the use of cost-effective alternatives to expensive services (Ridgely & Willenbring, 1992). They can produce cost savings by managing care, including substituting less costly, more appropriate services and sometimes simply by not authorizing higher-cost services. Rather than facilitating access, gatekeepers must restrict access to control utilization and, thereby, costs. The ability of these case managers to create savings depends on the availability of appropriate cost-effective alternatives, case manager authority within the care system, and case manager ability to control financing for the care they deem appropriate (Ridgely & Willenbring, 1992). The case manager functions much like a purchasing agent (Clark, 1996).

Focused on catastrophic diseases or events such as acquired immunodeficiency syndrome (AIDS) or brain injuries, catastrophic CM is often used with workers’ compensation cases and life-care planning. It is designed to manage and maximize insurance and health care benefits, which may be capped at a lifetime maximum. Early warning strategies are adopted to detect the potential for high-cost cases and to deal with both clients and service providers proactively to optimize and economize the health services used (Cline, 1990).

In HMO (managed care) models, prospective or capitated reimbursement systems put providers at financial risk. This creates pressure on providers to control total costs, provide and promote prevention-oriented services, and substitute lower-cost services, preferably without sacrificing quality. One example of managed care models is integrated health care, defined as a network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is held accountable for the population’s health status (Shortell et al., 1993). Federal, state, and local government agencies also manage and reimburse care via programs such as Medicare, Medicaid, and workers’ compensation.

Few interdisciplinary models exist. The following two were described in the literature:

1. One model for acute care case management for nurses and social workers has been described (Dzyacky, 1998). It is a program designed to integrate utilization management functions with discharge planning and separate the practice of social work from discharge planning activities. Discharge planning tasks were divided into two categories—simple and complex. Case facilitator nurses became responsible for simple discharge planning cases; social workers handled the complex category.

2. One model for nurse–social worker collaboration in managed care also has been presented (Hawkins et al., 1998). Called the Biopsychosocial Individual and Systems Intervention Model, it is derived from a combination of interdisciplinary collaboration models at the organizational and administrative levels and a case management intervention approach for individuals and small systems levels. Nurses and social workers are assumed to collaborate as equal partners in interdisciplinary team case management using a transdisciplinary model.

The one general, overarching model that is becoming widely accepted as the generic case management model is Wagner’s Chronic Care Model (Improving Chronic Illness Care, 2012; Wagner et al., 2001). The Chronic Care Model addresses concerns about how to manage chronic illnesses. The six elements of the health care system that encourage quality chronic illness care are the community, the health system, self-management support, delivery system design, decision support, and clinical information systems. The specific concepts related to the six elements are patient safety, cultural competency, care coordination, community policies, and case management. Chronic disease/illness care is important because almost one half of all Americans (145 million people) live with a chronic condition. For older adults, 43% have three or more illnesses (Improving Chronic Illness Care, 2012). This order of magnitude has generated great interest in strategies to be proactive and focused on keeping people as healthy as possible. Case management is an attractive strategy because it is aimed at care coordination and decreased system-related fragmentation.

History of Case Management

Different disciplines practice case management; thus the history of its development varies according to the perspective of the specific discipline reporting it. The social work perspective is that the roots of CM grow from social work’s historical tradition and the work of Mary Richmond in the era of the early settlement houses and charity organization societies (Raiff & Shore, 1993). This was a social casework concept at the turn of the twentieth century. Since the 1970s there has been a resurgence in CM as a result of shifts in the locus and financing of health care and human services and problems with service fragmentation and inaccessibility.

The insurance companies’ perspective is that CM arose in insurance companies because of the need to manage catastrophic and high-cost cases. For example, Liberty Mutual is often credited with having pioneered the concept of in-house case management/rehabilitation programs in insurance companies in 1943 as a cost-containment measure for workers’ compensation. This concept was expanded in 1966 by the Insurance Company of North America (now CIGNA) when it started an in-house program incorporating vocational rehabilitation and CM that later became the company Intracorp. Some view George Welch of CIGNA as the true father of modern CM, as demonstrated in the following perspective (Siefker et al., 1998, p. 3):

The history of CM in nursing began with private duty nursing, the oldest care modality in U.S. nursing. With the rise of the early settlement houses, coordination of health care services for immigrants and the poor was a concern. This was the beginning of public and human services in the United States. Both nurses and social workers were key initiators. The Henry Street Settlement was founded in 1895 by two nurses (identified as social workers), Lillian Wald and Mary Brewster. In 1902, Lillian Wald founded the first school of nursing. By 1900, visiting nurse services were established to provide comprehensive community services and case coordination (Tahan, 1998).

Community service coordination, a forerunner of CM, began at the turn of the twentieth century in public health programs. The Visiting Nurse Service was one of the first community health programs. Providing service coordination has always been a focus of public health nursing. Service coordination has since evolved into CM, but case management considerably expands on coordination of community services. The concept of a continuum of care was used after World War II to describe the extended community services needed for mental health clients. The term case management first appeared in the early 1970s in social welfare literature, followed by a use in the nursing literature. The 1981 Omnibus Budget Reconciliation Act plus Medicare prospective reimbursement encouraged comprehensive, coordinated services. As a result of changing reimbursement structures, insurers have been focused on programs to contain the rising costs of health care. Case management emerged in the fields of psychiatry and social work in the 1920s, was used by visiting nurses in the 1930s, developed and flourished in acute care in the 1980s, and was found in all settings in the 1990s (Cesta & Tahan, 2003).

In nursing, CM historically has been the care delivery model associated with public health and community health nursing. Thus it was operational in settings outside hospitals and operated without the umbrella of managed care. In these settings, CM focused on accountability of process and outcomes of care delivery. Traditional CM principles also were operational in several care models that evolved over time. CM also was used in social service agencies, community mental health services, rehabilitation settings, and long-term care.

In the 1960s, contemporaneous with government legislation enacting Medicare and Medicaid coverage, the insurance industry began to evolve CM models (Siefker et al., 1998). This pre-emergence decade set the stage for a series of dramatic evolutionary changes in CM each decade since the 1960s.

Many trace the “rise” of CM models to the 1970s. Certainly the past 35 years or so have brought about an amazing growth and change. The effects have been dramatic. In the 1970s, as the federal government began to analyze actuarial data on health care costs, expenditures, and projections, CM became a useful strategy in health maintenance organizations (HMOs), long-term care demonstration grants, and social work efforts to manage the deinstitutionalization of the chronically mentally ill. The 1970s saw the rise of both solo providers of CM services (independent companies) and large national CM companies. Models of catastrophic CM and workers’ compensation predominated, and the certification as certified rehabilitation counselor (CRC) began.

The 1980s saw a decade of rapid spread and wild growth in CM models. With the advent of DRGs and prospective payment mechanisms, CM came to be seen as one answer to cost stabilization and cost predictability. It spread into models of social health maintenance organizations and other insurance settings. Independent CM companies grew and thrived. The certified disability management specialist (CDMS) certification was begun, and the New England Medical Center’s nursing CM (acute care) model was developed and disseminated into hospital-based CM.

The decade of the 1990s was a time of integration and knowledge explosion. Interest that had been sparked in the 1980s carried over into the 1990s as health care providers, payers, employers, health plans, and professional organizations struggled to integrate CM practice and identify the knowledge base. Two groups merged to form the professional organization representing CM practice: the Case Management Society of America (CMSA). The Commission for Case Manager Certification (CCMC) was established and offered the certified case manager (CCM) credential. A proliferation of other certifications, usually within provider disciplines, occurred. CMSA developed and published standards of practice (SOP) for CM in 1995 and updated this in 2002 and again in 2010. Both CMSA and CCMC adopted the same consensus definition of CM, although CMSA modified its definition in 2002. The managed care technique of utilization management became more closely aligned with CM. Models of CM also proliferated, usually within hospitals and the acute care sector, but without standardization. Jobs for case managers began to shift into acute care, the insurance industry, and large private companies. Organizational accreditation for CM programs was introduced by the Commission on Accreditation of Rehabilitation Facilities (CARF) and the Utilization Review Accreditation Commission (URAC). Rigorous research results began to emerge to demonstrate the value of CM models. CM models came under scrutiny for their value and cost-effectiveness.

Interest arose in using CM principles and applying them to populations with chronic diseases, which was the pre-emergence phase of disease management. With the multiple reports from the IOM and the passage of the ACA in 2010, care coordination became front and center. There is intense interest and activity now around both strategies of CM for individual patients and PHM for disease and population health management.


Sometimes called care management, outcomes management, or clinical resource management, CM has elements related to access, decision support, and outcomes achievement. Other CM functions are access, utilization review and management, discharge planning or transition management, episode tracking and continuous quality improvement, health prevention and disease management, and contracting. These functions may be stand-alone or combined in various ways, especially in hospitals in which the functions of utilization review and discharge planning can be balanced (Birmingham, 2007). The CM process is represented by the activities that case managers perform. CCMC (2012) has identified the eight essential CM activities with direct client contact as: (1) assessment, (2) planning, (3) implementation, (4) coordination, (5) monitoring, (6) evaluation, (7) outcomes, and (8) general activities. The six core components to CM practice, for exam purposes, are: (1) psychosocial aspects, (2) health care reimbursement, (3) rehabilitation, (4) health care management and delivery, (5) principles of practice, and (6) case management concepts.

According to the CMSA’s Standards of Practice for Case Management (2010), the key functions of a case manager are assessment, planning, facilitation, and advocacy. Collaboration with the client and with those involved in the client’s care is essential. Specialized skill and knowledge are needed in positive relationship building; effective communication; negotiation; knowledge of contractual and risk arrangements; ability to affect change, perform evaluation, plan and organize, and promote autonomy; and knowledge about funding sources, health care services, human behavior, health care financing, and clinical standards and outcomes. The process of CM begins with the identification of individuals with high-cost, complex care needs who can benefit from CM services. The case management intervention begins with first contact with the client and/or family and continues as an ongoing relationship until termination.

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Aug 7, 2016 | Posted by in NURSING | Comments Off on Case and Population Health Management

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