Care management is a health care delivery process that helps achieve better health outcomes by anticipating and linking clients with the services they need more quickly (CMSA, 2010). It is an enduring process in which a population manager establishes systems and processes to monitor the health status, resources, and outcomes for a targeted aggregate of the population. The population manager is the tactical architect for a population’s health in the delivery system. Building blocks that are used by the manager include risk analysis; data mapping; monitoring for health processes, indicators, and unexpected illnesses; epidemiological investigation of unexpected illnesses; development of multidisciplinary action plans and programs for the population; and identifying case management triggers or events (e.g., when dramatic results are obtained by prevention or early intervention) that indicate the need for early referrals of high-risk clients (Haag and Kalina, 2005).

Care management strategies were initially developed by health maintenance organizations (HMOs) in the late 1970s to manage the care of different populations. The purpose was to promote quality and ensure appropriate use and costs of services. Typically these involved clients with reduced self-care capacity and whose diseases and treatments were intense (Michaels and Cohen, 2005). Care management strategies include utilization management, critical pathways, case management, disease management, and demand management. Utilization management attempts to promote optimal use of services to redirect care and monitor the appropriate use of provider care/treatment services for both acute and community/ambulatory services. Providers are offered multiple options for care with different economic implications. Through the use of utilization management, clients who have repetitive readmissions (i.e., they fail to respond to care) are often referred to care management programs. Critical pathways and maps, which were more popular in the early 2000s, are tools that specify activities providers may use in a timely sequence to achieve desired outcomes for care. The outcomes are measurable, and the pathway tools strive to reduce differences in client care. Today, agencies are more likely to use clinical paths, evidence-based practice protocols or guidelines, or case management plans of care. Case management services are used for clients with specific diagnoses who may have high-use patterns, non-compliance issues, cost caps (e.g., no more than $10,000 to $20,000 can be spent on their case), or threshold expenses.

Disease management constitutes systematic activities to coordinate health care interventions and communications for populations with conditions in which client self-care efforts are significant (CMSA, 2010). For example, diabetes, asthma, and depression are typically targeted by providers and insurers. These programs have evolved largely as initiatives in managed care organizations (Huber, 2010).

Demand management seeks to control use by providing clients with correct information and education strategies to make healthy choices, to use healthy and health-seeking behaviors to improve their health status, and to make fewer demands on the health care system (Tufts Managed Care Institute, 2011).

In contrast, case management comprises the activities implemented with individual clients in the system. The case manager builds on the basic functions of the traditional nurse’s role and adapts new competencies for managing transitions from health care facility to home, such as wellness and prevention, and interprofessional teams). Case management is the single most frequent intervention reported by 91% of staff public health nurses (Grumbach et al 2004). Case management is provided by the disciplines of nursing, social work, and rehabilitation counseling, to name a few. Research by Park, Huber, and Tahan (2009) found that common knowledge exists for case management providers from the disciplines of nursing, social work, and rehabilitation counseling: case recording and documentation, conflict resolution strategies, negotiation, ethics, relevant legislation, interpersonal communication, and roles and functions required in various settings. Figure 22-1 illustrates the unified knowledge domains for professionals in case management and emphasizes the fluidity of common knowledge used by case managers regardless of discipline. In addition, case managers in case-management programs are expanding their clinical expertise to embrace the process of disease management, a successful strategy for population outcomes. Specialty case management in advanced nursing practice is a critical role in this field (Cohen and Cesta, 2005). In implementing case management, these nurses work with clients or community aggregates as well as systems managing disease and outcomes, whereas nurses with bachelor’s degrees more often focus on care at the individual level (Stanton and Dunkin, 2002).

This chapter describes the nature and process of case management for individual and family clients. Case management has a rich tradition in public health nursing and is frequently found in hospitals, transitional and long-term care, home and hospice care, and health insurance companies. Case management is at the top of the care management pyramid, reserved for a subset of the population. In Figure 22-2 Coggeshall (2008) illustrates a case management model pyramid that recognizes the tenets of risk stratification and case finding, coordination, and ultimately case management of a smaller proportion of clients in the population. This model recognizes the interchange of public health and populations at risk for service intensity resulting from economic or care integration needs.

Reviewing multiple or historical definitions of case management helps to demonstrate the complex process and the concept of case management over time. Weil and Karls, in 1985, described case management as a “set of logical steps and process of interacting within a service network which ensures that a client receives needed services in a supportive, effective, efficient and cost-effective manner” (p 4). Case management was defined by the American Hospital Association (1986) as the process of planning, organizing, coordinating, and monitoring services and resources needed by clients, while supporting the effective use of health and social services. Secord (1987) defined case management as a systematic process of assessing, planning, and coordinating the service, referrals, and monitoring that meets the multiple needs of clients. Bower (1992) described the continuity, quality, and cost-containment aspects of case management as 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. A focus on collaboration is important in the National Case Management Task Force definition. The definition emphasizes a collaborative process between the case manager, the client, and representatives of other agencies and provider groups. The process includes assessments, plans, implementation, coordination, monitoring and the evaluation of the options and services to meet an individual’s health needs. Effective communication is essential to identify available resources to promote quality, cost effective outcomes (CMSA, 2010; Mullahy, 2010).

As a competency, case management was defined in the public health nursing literature as the “ability to establish an appropriate plan of care based on assessing the client/family and coordinating the necessary resources and services for the client’s benefit” (Muller and Flarery, 2003, p 230). Knowledge and skills required to achieve this competency include the following:

In the latest Standards of Practice for Case Management, case management is defined as “a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to facilitate an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes” (CMSA, 2010, p 24).

Case management practice is complex as evidenced by the need to coordinate activities of multiple providers, payers, and settings throughout a client’s continuum of care. For example, in a contemporary model of primary care practice, the medical home provides accessible, continuous, coordinated, comprehensive care and is managed centrally by a physician with the active involvement of non-physician practice staff. Care provided must be assessed, planned, implemented, adjusted, and evaluated on the basis of goals designed by many disciplines as well as goals of the client, the family, significant others, and community organizations. Although likely employed and located in one setting, the nurse as case manager will be influencing the selection and monitoring of care provided in other settings by formal and informal care providers. With the increased use of electronic care delivery through telehealth activities, case management activities are now handled via telephone, e-mail, and fax, and through video visits and electronic monitoring in a client’s residence. Case managers may also deliver care to a global network of clients located in different countries. A challenging problem is the fragmentation of services, which can result in overuse, underuse, gaps in care, and miscommunication. This can result in costly client outcomes and quality issues in hand-offs and transitions from provider to provider.

Case management differs between urban and rural settings. In the rural setting, where the distance between populations is more expansive, there are fewer organized community-based systems and communication and distance is often a greater challenge. Furthermore, the economics, pace and style of life, values, and social organization all differ. In a study by Stanton and Dunkin (2002) and later referenced in 2009 (Stanton and Dunkin), rural residents identified four barriers to access to care that confront case managers in rural areas: lack of proximity to providers, limited services, scarcity of providers, and availability of emergency and acute care services. Transportation, both for nurses and for clients, and lack of health insurance and benefits were documented challenges to rural clients of case managers. These issues were also identified by Waitzkin, Williams, and Bock (2002) as problems for rural clients in managed care systems. In a 2009 study, Stanton and Dunkin identified the need for safety during transitional care and by the nurse case managers. Specific actions included the need for effective communication, medication reconciliation during transitions, and coordination of care among multiple providers for rural clients in a rural nurse-managed clinic. These actions are essential to support The Joint Commission’s National Safety Goals (2009).

DID YOU KNOW?

Although the activities in case management may differ among providers and clients, the following five goals are shared:

• To promote quality case management services to populations

• To reduce institutional care, fragmentation of care, and safety gaps in transition of care while maintaining quality processes and satisfactory outcomes

• To manage resource utilization through the use of protocols, evidence-based guidelines, utilization, and disease management programs

• To control expenses by managing care processes and outcomes

• To improve adherence to guidelines for quality case management by clients and providers

Modified from Flarey DL, Blancett SS: Case management: delivering care in the age of managed care. In Flarey DL, Blancett SS, editors: Handbook of nursing case management: health care delivery in a world of managed care, Gaithersburg, MD, 1996, Aspen.

DID YOU KNOW?

Medication non-adherence (appropriate medication-taking behaviors) is at an epidemic proportion. The number one problem with treating illness today is failure to take prescriptions correctly. As an example, for the cardiac client population:

• 12% fail to have their prescriptions filled.

• An additional 12% obtain initial supplies but do not take them.

• 29% of clients stop taking their medication before they have concluded the course of therapy.

• Although 50% of clients continue to take their medications, 22% of these take less medication than prescribed because of missed or skipped doses.

By following Case Management Adherence Guidelines, you can improve the benefits of medication therapy resulting from adherence with client populations.

From CMAG, Case Management Adherence Guidelines, 2006. Available at http://www.cmsa.org/portals/0/pdf/CMAG2.pdf. Accessed January 20, 2011.

Case Management and the Nursing Process

The nurse views the process of case management through the broader health status of the community. Clients and families receiving service represent the microcosm of health needs within the larger community. Through a nurse’s case management activities, general community deficiencies in quality and quantity of health services are often discovered. For example, the management of a severely disabled child by a nurse case manager may uncover the absence of respite services or parenting support and education resources in a community. While managing the disability and injury claims within a corporation, the nurse may discover that alternative care referrals for home-health visits and physical therapy are generally underused by the acute care providers in the community. Through a nurse’s case management of brain-injured young adults, the absence of community standards and legislative policy for helmet use by bicyclists and motorcyclists may be revealed, stimulating advocacy efforts for changing community policy. Case management activities with individual clients and families will reveal the broader picture of health services and health status of the community. Community assessment, policy development, and assurance activities that frame core functions of public health actions are often the logical next step for a nurse’s practice. When observing lack of care or services at the individual and family intervention levels, the nurse can, through case management, intervene at the community level to make changes. Clearly, the core components of case management and the nursing process are complementary (Table 22-1).

TABLE 22-1

THE NURSING PROCESS AND CASE MANAGEMENT

NURSING PROCESS	CASE MANAGEMENT PROCESS	ACTIVITIES
Assessment	• Case finding • Identification of incentives for target population • Screening and intake • Determination of eligibility • Assessment	• Develop networks with target population • Disseminate written materials • Seek referrals • Apply screening tools according to program goals and objectives • Use written and on-site screens • Apply comprehensive assessment methods (physical, social, emotional, cognitive, economic, and self-care capacity) • Obtaining consent for services if appropriate
Diagnosis	• Identification of problem/opportunity	• Hold interprofessional, family, and client conferences • Determine conclusion on basis of assessment • Use interprofessional team
Planning for Outcomes	• Problem prioritizing • Planning to address care needs • Identify resource match	• Validate and prioritize problems with all participants • Develop goals, activities, time frames, and options • Gain client’s consent to implement • Have client choose options
Implementation	• Advocate clients’ interests • Frequent monitoring to assess alignment with goals and changing nature of client needs	• Contact providers • Negotiate services and price • Adjust as implementation is needed • Document processes and monitor progress
Evaluation	• Measure attainment of activities and goals of service delivery plan • Continued monitoring of client status during service • Reassessment • Bring closure to care when client needs are achieved or change • Discharge appropriately	• Ensure quality of transitional communication and coordination of service delivery • Monitor for changes in client or service status • Examine outcomes against goals • Examine needs against service • Examine costs • Examine satisfaction of client, providers, and case manager • Examine best practices and outcomes for this client

Secord’s (1987) classic illustration of case management remains an appropriate picture of the process that nurses use. The CMSA model (2010) is a contemporary illustration of the case manager’s process in the continuum of care (Figure 22-3).

Characteristics and Roles

Case management can be labor intensive, time consuming, and costly. Because of the rapid growth in the nature of complexity in clients’ problems, the intensity and duration of activities required to support the case management function may soon exceed the demands of direct caregiving. Managers and clinicians in community health are exploring methods to make case management more efficient. In an earlier effort to achieve efficiency (Weil and Karls, 1985), the characteristics desired for case manager effectiveness were described. These characteristics, which incorporated the four CMSA activities (previously noted in the Concepts of Case Management section), are used today (CMSA, 2010):

1. The technical qualifications to understand and evaluate specific diagnoses, generally requiring clinical credentials (and experience), financial resources and analyses, and risk arrangements

2. Capability in language and terminology (able to understand and then to explain to others in simple terms)

3. Assertiveness, diplomacy, and negotiation skills with people at all levels

4. The ability to assess situations objectively and to plan appropriate case management services

5. Knowledge of available clinical evidence and resources as well as their strengths and weaknesses

6. The ability to act as advocate for the client and payer in models relying on third-party payment

7. The ability to act as a counselor or facilitator to clients to provide support, understanding, information, and intervention

In 1998, Cary described the roles of case managers in the practice setting. These roles are clearly affirmed today in the work of Llewellyn and Moreo (2001) and by the CMSA (2010) (Box 22-1). The roles demanded of the nurse as case manager are greatly influenced by the forces that support or detract from the role. Figure 22-4 presents factors that demand the attention of both the nurse and the client during the case management process.

NURSING TIP

Use the components of the nursing process when executing the functions of a case manager with clients. Incorporate your knowledge of community resources, human behavior dynamics, cultural competency, financial eligibility, health promotion, disease trajectories, and advocacy as you execute the process.

BOX 22-1

CASE MANAGER ROLES

• Broker: Acts as an agent for provider services that are needed by clients to stay within coverage according to budget and cost limits of health care plan

• Consultant: Works with providers, suppliers, the community, and other case managers to provide case management expertise in programmatic and individual applications

• Coordinator: Arranges, regulates, and coordinates needed health care services for clients at all necessary points of services. Effectively participates on interprofessional teams

• Educator: Educates client, family, and providers about case management process, delivery system, community health resources, and benefit coverage so that informed decisions can be made by all parties

• Facilitator: Supports all parties in work toward mutual goals

• Liaison: Provides a formal communication link among all parties concerning the plan of care management

• Mentor: Counsels and guides the development of the practice of new case managers

• Monitor/reporter: Provides information to parties on status of member and situations affecting client safety, care quality, and client outcome, and on factors that alter costs and liability

• Negotiator: Negotiates the plan of care, services, and payment arrangements with providers; uses effective collaboration and team strategies

• Client advocate: Acts as advocate, provides information, and supports benefit changes that assist member, family, primary care provider, and capitated systems

• Researcher: Accesses and applies evidence-based practices for programmatic and individual interventions with clients and communities; participates in protection of clients in research studies; initiates/collaborates in research programs and studies; accesses real-time evidence for practice

• Standardization monitor: Formulates and monitors specific, time-sequenced critical path and care map plans (see text) as well as disease management protocols that guide the type and timing of care to comply with predicted treatment outcomes for the specific client and conditions; attempts to reduce variation in resource use; targets deviations from standards so adjustments can occur in a timely manner

• Systems allocator: Distributes limited health care resources according to a plan or rationale

Knowledge and Skill Requisites

Nurses are not automatically experts in the role of case manager. First, they develop and refine the knowledge and skills that are essential to implementing the role successfully. Knowledge domains useful for nurses in systems desiring to implement quality case management roles are found in Box 22-2 (Cary, 1998; Llewellyn and Moreo, 2001; Stanton and Dunkin, 2009).

BOX 22-2

KNOWLEDGE DOMAINS FOR CASE MANAGEMENT

• Standards of practice for case management

• Evidence-based practice guidelines for specific health and disease conditions and communities

• Knowledge of health care financial environment and the financial dimension of client populations managed by nurses

• Clinical knowledge, skill, and maturity to direct quality timing and sequencing of care activities

• Care resources for clients within institutions and communities: facilitating the development of new resources and systems to meet clients’ needs

• Transition planning for ideal timing, sequencing, and levels of care

• Management skills: communication, delegation, persuasion, use of power, consultation, problem solving, conflict management, confrontation, negotiation, management of change, marketing, group development, accountability, authority, advocacy, ethical decision making, and profit management

• Teaching, counseling, and education skills

• Program evaluation and research

• Performance improvement techniques

• Peer consultation and evaluation

• Requirements of eligibility and benefit parameters by third-party payers

• Legal and ethical issues

• Information management systems: clinical and administrative

• Health care legislation/policy

• Technical information skills, interoperable information systems, data management, and analysis

• Outcomes management and applied research

When a nurse seeks a case manager position, some of the skills and knowledge will need to be acquired through academic and continuing education programs, literature reviews, and orientation and mentoring experiences. Basic nursing education may need to be updated, while practical experiences in case management may be required. In fact, professional development activities for case managers in public health have been demonstrated to contribute to job satisfaction (Schutt et al, 2010).

Tools of Case Managers

The five “rights” of case management are right care, right time, right provider, right setting, and right price. How does the nurse judge the effectiveness of case management? Three tools are useful for case management practice: case management plans, disease management, and life care planning tools. An underlying principle for use of each of these tools is the need to use robust evidence as the basis for the selection of activities.

Case management plans have evolved through various terms and methods (e.g., critical paths, critical pathways, care maps, multidisciplinary action plans, nursing care plans). Regardless of the title given, standards of client care, standards of nursing practice, and clinical guidelines using evidence-based practices for case management serve as core foundations of case management plans. Likewise, in interprofessional action plans, core professional standards of each discipline guide the development of the standard process.

As early as 1985, the New England Medical Center in Boston instituted a system of critical path development to guide the case management process in the acute care setting. A critical path was described as a case management tool comprised of abbreviated versions of discipline-specific processes; it was used to achieve a measurable outcome for a specific client “case” (Zander, Etheredge, and Bower, 1987). The critical path detailed the essential and sequential activities in care, so that the expected progress of the client was known at a point in time. Outcomes from critical paths included satisfaction, client competency, continuity of care, continuity of information, and costs and quality of care. However, one criticism was that critical paths may not be evidence based (Renholm, Leino-Kilpi, and Suominen, 2002). The prevailing method of establishing critical paths was by internal, “expert knowledge” from a specific institution, the result being that they could not be applied generally or tested under systematic, scientific methods. In the New England model, key incidents included consults, tests, activities, treatments, medication, diet, discharge planning, and teaching. The paths showed the differences between clients’ progress. However, the paths were generally not revised unless a body of evidence was found to adjust the expected actions.

Care maps became the second generation of critical pathways of care. Rather than give definitions, Brown (2001) discussed the “various types of evidence that must be accessed, interpreted, and integrated into care design.” Brown (2001, p 3) proposed the Best Practice Health Care Map (BPHM) as a model for providing quality clinical care within an interprofessional practice. This model discussed all the components of knowledge development and care planning activities that must occur to have positive client outcomes. The author noted that care designed in advance takes the form of “clinical guidelines, care maps, decision algorithms, and clinical protocols for specified populations of clients” (Brown, 2001, p 3). The “Pre-specification Design” of the BPHM entailed these preplanning courses of care. Brown (2001) stressed the importance of incorporating research findings and clinical experience when developing prespecified plans. Furthermore, the author emphasized that at the point of care, these prespecified plans must be adapted to the individual client or population.

The Brown BPHM was: (1) client centered, (2) scientifically based, (3) population-outcomes based, (4) refined through quality assessment and compared with other maps, (5) individualized to each client, and (6) compatible with the larger system of health care in the United States such activities are more likely referred to as case management plans, care maps, and integrated clinical pathways (Figure 22-5).

Adaptation of the case management care plan to each client’s characteristics is a crucial skill for standardizing the process and outcome of care. It links multiple provider interventions to client responses and offers reasonable predictions to clients about health outcomes. Institutions report that sharing case management plans with clients empowers the clients to assume responsibility for monitoring and adhering to the plan of care. Self-responsibility by clients incorporates autonomy and self-determination as the core of case management. For the nurse employed to function as a case manager, ample opportunity exists to develop, test, and revise critical path/map prototypes for a target population experiencing acute health problems.

Disease management is an organized program of coordinated health care interventions and communications for populations with conditions in which client self-care efforts are critical (CMSA, 2010). This approach focuses on the natural progression of a disease. Disease management programs may contain many of the following components (DMAA, 2008, 2010):

• Financial and risk sharing arrangements between payers and providers

• Programs for monitoring the use of clinical paths and evidence-based guidelines to assess outcomes and costs

• Protocols for clinical and administrative processes as well as cost allocations

• Services to educate clients and promote self-management skills

• Enhanced quality through evidence-based decision support and other registry technologies

• Support for provider/client relationships and plans of care

• Evaluation of clinical, humanistic, and economic outcomes to address the goal of improving overall health

HOW TO

Apply Telehealth Interventions for Clients

To learn more about telehealth interventions for clients, case managers can do the following:

• Make it a point to learn how telehealth works in your community and in the industry.

• Examine the evidence base for telehealth as an option when considering available resources.

• Seek continuing education courses to prepare you on the art and science of telehealth application. Read the literature on e-communication and monitoring effectiveness impact.

• Seek networking opportunities with professional organizations and other case managers about the uses of telehealth.

• Examine the clinical guidelines and practice algorithms for telehealth adoption, application, and use.

• Sharpen your personal interaction and program evaluation skills to better assist in decision making about the use of telehealth services.

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