CARE COORDINATION AND INTEGRATION

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.

DEFINITIONS

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 OVERVIEW

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:

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:

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:

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:

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.

THE CASE MANAGEMENT PROCESS

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.

Advocacy

Case management advocacy is a function related to client empowerment, autonomy, and self-determination. Advocacy actions are supportive and educative and represent the client’s best interests. Representing the client’s best interest includes advocating for early referral, necessary funding, appropriate treatment, and timely coordination of services. When conflicts arise, the case manager’s role is to advocate for the needs of the client (CMSA, 2010).

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