A. Rapid change is dominating the health care landscape, and acute care case management programs are feeling the pinch. Hospital case management is on a rapid evolutionary track as hospital programs respond to the changes in the marketplace, the same dominant marketplace that prompted its origins back in the early 1980s.

B. The market shift toward value-based care (VBC) presents unprecedented opportunities and challenges for the US health care system. Instead of rewarding volume, new value-based payment models reward better results in terms of cost, quality, safety, patient experience of care, and other outcome measures.

C. To keep up with demands for better outcomes, hospital case management (HCM) programs are moving to more contemporary models, and they are exploring opportunities to extend care management beyond the traditional walls of the hospital and across the full care continuum for selected high-risk patients. In adapting to new expectations, the traditional, functional case manager role as a utilization reviewer and discharge planner is disappearing. New blended roles of case managers are evolving and supported by other members of the case management team assuming specialized focus on utilization review and discharge planning.

D. Today, successful HCM programs are the orchestra leaders helping the various musicians stay in tune and keep up the tempo as the patient progresses through the acute episode of care. In keeping with the Institute of Healthcare Improvement’s (IHI’s) Triple Aim (better care, better health, and lower cost), today’s case management programs are designing infrastructures and workflow process to promote the right care, in the right place, at the right time—every time. This ultimately is improving the quality of patient care, reducing the costs of care, and enhancing an optimal patient’s experience of care.

E. The practice of hospital case management is no longer defined by UR and discharge planning functions. Today’s models are more reflective of the actual definitions promulgated by the professional case management societies and are designed to achieve desired outcomes in the current fee-for-service environment while preparing for the leap “from the first curve, or volume-based environment, to the second curve, building value-based systems and business models.”

F. According to industry observers, hospitals will succeed in the current environmental chaos by establishing partnerships with their stakeholders and postacute care partners to develop solutions tailored to selected patient populations.

G. From the perspective of many hospital executives who are preparing their organizations for a future of bundled payment methods, capitation, shared savings plans, medical homes, and accountable
care organizations, HCMs are now challenged to achieve three major outcomes for selected patients:

H. The new generation of hospital case management programs is typically structured and operationalized to rapidly achieve these three goals. Within these programs, there are many features that should be integrated into every hospital’s program no matter where they are on the evolutionary scale (Daniels & Ramey, 2005).

The understanding of these terms is important to case management practice but may not be expanded upon within this chapter’s content.

A. Advocacy—A proactive process that promotes beneficence, justice, and autonomy for clients. To the extent possible, advocacy in the acute care setting aims to foster the client’s engagement in decisions affecting the goals of their treatment plan. It involves educating clients about their rights, resources available, and insurance benefits. Advocacy facilitates appropriate and informed decision making and includes considerations for the client’s values, beliefs, and interests (Gilpin, 2005).

B. Congruency—Congruency refers to the “fit” between the case management program and its environment. The environment includes the unique cultural climate that is internal to the organization and the external pressures of the marketplace.

C. Coordination of care—Organizing activities and sharing information among the care team to achieve safer and more effective care outcomes in accordance with the patients’ needs and preferences.

D. Discharge planning—The process of assessing the patient’s needs after leaving the acute care/hospital setting or another health care facility and ensuring that these services are in place for the patient before leaving.

E. Infrastructure—Relates to the alignment of hospital case management within the organizational structure; the composition and positions of team members; and the assignment, staffing, and scheduling of case management team positions.

F. Progression of care (PoC)—Encompasses a diverse set of activities designed to influence the efficient and effective movement of selected patients through the acute episode of care leading to a safe and timely transition to another level of care including home.

G. Transitional planning—A process applied to ensure that necessary resources and services are provided to a patient and that these services are delivered in the most appropriate level of care based on the patient’s health condition and needs and in consideration with applicable laws and regulations or standards.

H. Utilization management—A process that focuses on the review of services and resources offered to patients on the basis of medical necessity, in the most relevant care setting/level of care, and in concert with quality and safety standards. A special focus here is cost-effective allocation of resources.

I. Utilization review—A mechanism used by some health insurance plans/payers to evaluate health care services provided (or about to) to a patient on the basis of necessity, appropriateness, and quality.

J. Workflow processes—Day-to-day case manager activities specifically designed to deliver the scope of practice to a selected patient population.

A. The Case Management Society of America (CMSA) describes in its standards of practice for case management that case management extends across all health care settings (CMSA, 2010). This without a doubt includes acute care/hospital levels of care, the subject of this chapter.

B. Case managers, according to CMSA, are recognized as expert clinicians and vital participants in the case management team. They empower people to understand and access quality, safe, cost-effective, and efficient health care services in the various care settings across the continuum and by diverse providers; acute care is one of these settings (CMSA, 2010).

C. Case managers in acute care settings focus on a variety of roles and functions described in CMSA’s standards of practice for case management. Of special importance are care coordination, transitions of care, utilization management, and discharge/transitional planning. These are even more important considering the type of patients case managers care for in the acute care setting: individuals with multiple chronic illnesses and of various age groups especially the elderly.

D. CMSA’s standards of practice highlight special activities that are pertinent to this chapter. These include client selection process for case management services, client assessment, problem or opportunity identification, planning care, monitoring of progress, evaluation of outcomes, facilitation and coordination of care and services, collaboration with other health care professionals, resource management, and stewardship (CMSA, 2010).

E. Case managers according to CMSA’s standards conduct a comprehensive assessment of the client’s health and psychosocial needs and develop a case management plan collaboratively with other members of the interdisciplinary health care team but most importantly with the client and family or caregiver. Focus of these activities is the movement of the patient to the most appropriate level of care. These functions are integral to the role of case managers in the acute care setting.

F. The acute care settings are characterized by higher complexity and intensity of services and resources compared to other care settings. It is highly important for acute care case managers to facilitate communication and coordination among the various members of the health care team and involve the patient/family or caregiver in the
decision-making process about their care options, especially those needed postdischarge from acute care.

G. CMSA in its standards of practice for case management highlights the importance of advocacy in case management practice (CMSA, 2010). Case managers advocate for both the client and the payer in an effort to facilitate positive outcomes for the client, the health care team, and the payer, while keeping the needs of the client as the primary priority. This chapter describes the role case managers play in this regard.

A. Hospital case management has its roots in the expanded role of the clinical nurse at Massachusetts’ New England Medical Center (Zander, 1988). A “nurse case manager” followed a patient throughout the episode of care to overcome obstacles that may delay discharge. It was conceived as a strategy to lower lengths of stay at the time when the new PPS was introduced and to increase revenue or reduce financial risk.

B. Following the introduction of the PPS in the early 1980s, more than 1,000 hospitals went bankrupt and were closed or acquired, and there was a scramble to quickly reduce costs. Management engineers collapsed social work and UR departments and created case management programs. The concept of progressing the patient’s care got lost in the shuffle, and we’ve been living with variations of this functional model ever since.

C. With the publication of Institute of Medicine’s (IOM’s) report, To Err Is Human (1999), the marketplace shifted once again and demanded improved outcomes in care and costs. Hospital case management programs responded by returning to its roots, focusing on progression of care to improve outcomes. At the same time, the UR function expanded exponentially with the growing list of regulatory oversight agencies demanding appropriate use of hospital level of care services. This leads to the creation of dedicated teams of UR specialists skilled in navigating the morass of rules and regulations governing medical necessity.

D. As the US hospital industry continues to change in structure, delivery of care, and payment models, the case manager has emerged as an important part of the workforce and a key driver of managing access to care, coordination of care, and cost/quality outcomes of care across the entire health care continuum.

E. Delivering patient-centered care and services is one of the goals CMSA describes in its standards of practice. This is especially synergistic with the demands imposed on the health care delivery system by the Patient Protection and Affordable Care Act of 2010. It is also a requirement in acute care settings and necessary focus of the role of the case manager in these settings.

A. The primary purposes of case management—to advocate on behalf of the patient and facilitate access to and the delivery of safe, appropriate care in a cost-effective manner, while seeking to promote positive health care outcomes—remain constant regardless of the practice
venue. However, the practice of case management in a hospital looks quite different from case management practiced in a community health program or a health insurance company.

B. There are three key dimensions that distinguish case management in the hospital from those in other practice venues, and each dimension reflects the changing marketplace. These include designation of the program, congruency, and leverage.

C. Designation of the program:

D. Congruency

E. Leverage

A. Hospital case management operates within a supply-driven market. It is generally the provider (the physician) rather than the consumer (the patient) who determines the type and extent of treatment, care, or services required.

B. To a modest degree, the explosion of the baby boomers, transparency in public reporting, the Internet, and direct-to-consumer advertising have eroded a portion of this market. Nevertheless, within the acute care environment, it is safe to say that, for the most part, the physicians’ practice choices drive resource consumption, costs, and clinical outcomes.

C. To influence the type and extent of practice choices and promote appropriate and cost-effective interventions, a collaborative partnership between the case manager and the physician must be nurtured. Aligned with such partnership is another between the case manager and the patient/family/caregiver.

D. Case manager-physician partnerships are not forged overnight. While community-based primary care providers (PCPs) are generationally more resistant to partnerships, the presence of hospitalists has positively shifted the landscape since they are often working under incentive-based contracts and will seek the support of an HCM to navigate the system and achieve aligned goals.

E. Working in partnership with the physician may mean adopting new styles of communication or a new attitude. It means that the case manager will probably be making rounds with the physician partner whenever feasible, questioning practice decisions and offering alternatives, and coaching the physician on the “business” of managing the patients’ care. Optimal patient advocacy requires continual diligence
during the patient’s progression of care to minimize the patient’s exposure to unnecessary risk. Successful case managers work with the physician not around him/her.

F. Despite the case manager’s level of clinical competence, the case manager’s role is not to exercise clinical skills, but rather to apply critical thinking and clinical judgment skills, knowledge of health care treatments, familiarity with evidence-based interventions, and erudition of the health care system to influence the physician’s medical decision making. To promote a safe, cost-effective episode of acute care, forging a relationship with the physician and provider team is essential (Commission for Case Manager Certification, 2010).

G. To influence a physician so that treatment decisions are made timely, appropriately, and in the patient’s best interest, a conceptual shift to problem solving from the customer’s perspective must occur and become second nature to the hospital case manager. If the case manager can recognize what is important to the physician, that insight can be used to offer a trade, or exchange, that brings value to the physician in practical terms.

H. Generally, physicians want help in effectively managing their time while in the hospital. They are interested in having:

I. By and large, physicians will not buy into a case management program, and acceptance will never occur if the physician perceives the role of the case manager as being simply to police his/her patients’ charts, reduce length of stay, cut costs for the hospital, or challenge his/her medical judgment.

A. As programs continued to evolve, no single “reference model” of acute care case management has emerged. As a result, hospital case management today is often a reactive conglomeration of activities without a coherent vision or rational intent.

B. Envisioning the future—Given the chaos in the current hospital environment, coupled with the lack of a reference model for hospital case management, every successful program planner first creates a vision for the model.

C. While determining the purpose and intent of the hospital’s case management program, important and sensitive outcomes are articulated. Knowledge at the outset on how hospital case management will be evaluated gives planners information to help design a relevant infrastructure and operations.

D. While many hospitals continue to use functional, second-generation, task-oriented models, outcome models represent the current best practice in many hospitals that are preparing for the future of VBC where appropriate resource utilization management is critical and where care coordination across the continuum has been initiated.