A. Case management has been applied as a strategy, process, system, or a model for care delivery in every setting of the health care continuum.

B. There are many reasons for the implementation of case management models in various care settings across the continuum of health and human services. Some of these are shared in Box 4-1.

C. Case management is not a new approach to managing patient care. It has reached every health care setting across the continuum.

D. The use of case management varies from one practice setting to another, with its identifying characteristics dependent on the discipline that applies it, the professional who assumes the role of the case manager, the staffing mix, and the context of the setting where it is implemented including its related reimbursement method(s).

E. The main characteristics of case management, regardless of care or practice setting, include those listed in Box 4-2.

F. Case management allows the integration and coordination of health care services across consumers of health care, providers of care, payers for
services, and care settings; that is, across persons, space, and time. This is most effective because case management

G. Case management gained more momentum when the health care delivery system began to gradually shift away from the inpatient care setting (hospital). Owing to numerous technological advances in diagnostics, medications, and procedures, and the evolution of reimbursement plans that limit inpatient hospital stays (e.g., Medicare’s prospective payment system and managed care health plans), most health care needs can be handled on an outpatient basis.

H. Case management has been described as “within the walls” and “beyond the walls” (Cohen & Cesta, 2005).

I. Case management has also been implemented as a core strategy of population-based disease management and population health programs.

J. Recently, case management became an essential strategy for ensuring care quality and patient safety, especially in reducing or preventing the risk for medical errors during transitions of care (handoffs), patient flow through the system of health care services and throughput, and core measures of the value-based purchasing programs such as low to no avoidable hospital readmissions.

A. Beyond-the-walls case management—Models of case management that are implemented outside the acute care/hospital setting; that is, in the community, outpatient clinics and physician practices, long-term care, ambulatory surgery centers, and payer settings.

B. Boarding patients—Occurs as a result of situations when a patient remains in an area such as the emergency department (ED) or postanesthesia care unit for a period of time, usually 2 hours or longer, after a decision has been made to admit the patient to an inpatient bed. Sometimes, this term is used when a patient is temporarily admitted to a specialty other than the one needed based on condition and care needs due to lack of beds in the appropriate setting; for example, surgical instead of a medical unit.

C. Crowding—Increased number of patients who are awaiting care or are in the process of receiving care in an area (i.e., care setting such as the ED)
beyond the capacity the area can handle. An example is ED crowding as a result of inability to move patients out of the ED and into inpatient beds when these patients must be admitted rather than released.

D. Diversion—Occurs when hospitals request that ambulances bypass their EDs and transport patients to other health care facilities who otherwise would have been cared for at these EDs. This event happens as a result of ED crowding and situations where EDs cannot safely handle additional ambulance patients.

E. Handoff—The act of transferring the care of a patient from one provider to another, from one care setting to another, or from one level of care to another.

F. Health care continuum—Care settings that vary across a continuum based on levels of care that are also characterized by complexity and intensity of resources and services. Sometimes, it is referred to as the continuum of health and human services; in this case, the focus is more on the type of services available across the care settings, which include those that address socioeconomic and psychosocial issues rather than just medical care.

G. Input—Elements or characteristics taken into consideration when providing care to a patient. It also may mean the patient’s condition at the time he or she presents for care in a particular care setting such as a clinic, emergency department, or hospital. Examples may include age, gender, health status, social network, reason for accessing health care services, or insurance status.

H. Left before a medical evaluation—Occurs when a patient who presents to the ED for care, but leaves the ED after triage and before receiving a medical evaluation. Generally, this happens with nonemergent conditions where patients need to wait for treatment of lowest type of urgency, usually nonlife sustaining.

I. Level of care—The intensity of resources and services required to diagnose, treat, preserve, or maintain an individual’s physical and/or emotional health and functioning. Levels of care vary across a continuum of least to most complex resources and/or services—that is, from prevention and wellness, to nonacute, rehabilitative, subacute, and acute, to critical.

J. Level of service—The delivery of services and use of resources that are dependent on the patient’s condition and the needed level of care. Assessment of the level of service is used to ensure that the patient is receiving care at the appropriate level.

K. Outcome—The result, output, or consequence of a health care process. It may be the result of care received or not received. It also represents the cumulative effects of one or more care processes on an individual at a defined point in time. Outcome can also mean the goal or objective of the care rendered.

L. Output—Results or outcomes of care provision. It also may mean the patient’s condition at the time he or she exits a health care setting, an episode of care, or transitions to another level of care, location, or provider. Examples may include death, discharge to home with home care or no services, or discharge to a skilled nursing facility.

M. Patient flow—The movement of patients through a set of locations in a health care facility. These locations are the levels of care required by the
patient based on health condition and clinical treatment. Patient flow entails the transitioning of an individual from point A to point B of a health care facility or setting; that is, from the patient’s entry point to the checkout point of the health care facility where care is being provided.

N. Practice setting—A care setting in which a case manager is employed and is able to execute his or her role functions and responsibilities. Care settings (and therefore practice settings) vary across homogeneous populations of patients such as organ transplant, pediatrics, and geriatric or across physical care delivery areas such as ambulatory clinics; acute hospital; long-term, skilled care facilities; subacute rehabilitation; or payer organizations.

O. Process—The methods, procedures, styles, and techniques rendered in the delivery of health care services. These relate to the roles, responsibilities, and functions of the various health care providers, including case managers, and how they go about fulfilling them.

P. Structure—The characteristics of the system/environment of care or health care organization including those associated with the providers of care and the patients/families who are the recipients of care. It relates to the level of care or setting, the nature of the care delivery model, the health and socioeconomic status of the patients, and the skills, knowledge, education, and competencies of the health care providers.

Q. Throughput—The actual operations of a care setting. It also refers to the clinical and administrative processes applied in the setting to deliver quality patient care and services. Processes may include the use of a case manager; availability of ancillary services such as pharmacy, laboratory, and radiology; and the type of treatments implemented for the care of a patient.

R. Transition of care—The process of moving patients from one level of care or provider to another, usually from most to least complex or from generalist to specialty care provider; however, depending on the patient’s health condition and needed treatments, the transition can occur from least to most complex.

S. Within-the-walls case management—Models of case management that are implemented in the acute care/hospital-based setting.

A. The Case Management Society of America (CMSA) describes in its standards of practice for case management (CMSA, 2010) that case management practice extends across all health care settings, including payer, provider, government, employer, community, and home environment.

B. CMSA explains that case management practice varies in degrees of complexity and comprehensiveness based on four factors:

C. This chapter describes the various care settings across the continuum of health and human services with special focus on the role of the case manager in these settings and the case management services provided.

D. CMSA identifies case management practice settings (Box 4-3) to include but not limited to those listed below. This chapter describes these settings based on the complexity of the services offered and the acuity of the health conditions of the patients cared for in these settings. The care settings are grouped into preacute, acute, and postacute types.

E. Although CMSA describes practice settings of case managers, these settings also may be viewed as patient care settings across the continuum.

A. Case management is practiced across all settings of the health care continuum in varying degrees of complexity and intensity and is dependent on five factors (Box 4-4).

B. The role of the case manager also varies based on the care/practice setting and the above five factors. It tends to be more complex as the needs and services a patient requires intensify. The role also is more necessary and valuable when a multidisciplinary team of providers is involved in the care of a patient compared to a single or primary care provider alone.

C. The best and most effective models of case management are those that focus on the continuum of care and settings. Regardless of the setting in which the model is implemented, it is most beneficial if
it facilitates (specifically in the role of the case manager) open lines of communication and collaborations/partnerships with health care providers practicing within and outside the setting where the patient is being cared for, emphasizes a patient- and family-centered approach to care provision, and ensures that the patient/family needs are addressed even beyond the setting the patient accesses for care.

D. According to Cesta and Tahan (2003), the health care continuum can be divided into three major settings based on the scope, type, and cost of services provided. These are preacute, acute, and postacute (Box 4-5).

E. The preacute case management practice settings include the following:

F. The acute case management practice settings include the following:

G. The postacute case management practice settings include the following:

A. Telephonic case management is defined as the delivery of health care services to patients and their families or caregivers over the telephone or via the use of various forms of telecommunication methods such as fax, e-mail, or other forms of electronic communication methods and digital technologies such as remote monitoring.

B. Most commonly used in the commercial health insurance or managed care organization (MCO) setting. It takes place in the form of communication between the MCO representatives (mostly MCO-based case managers) and its members.

C. Became more popular in the 1990s with the increased infiltration of managed care health plans. It was viewed as an essential strategy for cost containment. Today, this approach is also used in workers’ compensation and disability management.

D. Commercial health insurance plans and MCOs provide telephonic case management services as an additional benefit to their members. Through this strategy, telephonic triage and the provision of health advice have become more common. Through these approaches, case managers ensure the appropriate use of health care resources and allocated such resources based on the needs of the individual member.

E. Telephonic case management is considered a cost-effective, easily accessible, and proactive approach to preventing catastrophic health outcomes or deterioration in a patient’s condition that requires acute care or a hospital stay.

F. Case managers in the telephonic case management practice setting are available 24 hours per day, 7 days a week. The main focus of this access is triage services and utilization management of health care resources.

G. Case managers in the telephonic case management practice setting engage in specific case management activities such as those listed in Box 4-6.

H. Case managers in the telephonic case management practice setting also apply the case management process, however, without a face-to-face interaction with the patient or family. In this process, they

I. Telephonic case management is known to apply two main strategies to ensure cost-effectiveness and the provision of care in the most
appropriate setting and by the necessary care provider. These are as follows:

J. In deciding on the urgency of need for access to health care services, case managers place patients into three categories based on the findings of the telephonic assessment and evaluation. These are emergent, urgent, and nonurgent (Box 4-7).

K. In making triage decisions, case managers also use other information such as age, gender, past medical history and recent episodes of care, medication intake, allergies, and primary care provider. In addition, they may ask for health insurance plan-related information such as plan/account number, location of residence, and so on.

L. A rule of thumb for the case manager in telephonic triage is referring those who require care to the appropriate care provider and optimal setting.

A. Case managers in the payer-based setting are employees of the insurance company (i.e., health maintenance and managed care organizations).

B. In this setting, the main focus of case management is the health and wellness of the enrollee and the role of the case manager as a liaison between the providers of care—whether an individual or an agency/facility—and the insurance company.

C. Case managers are not the “claims police” despite the fact that they ensure cost-effective treatment plans. Rather, they are as follows:

D. In the payer-based setting, case managers build programs or systems that make it feasible to identify enrollees who are at risk for illness or avoidable disease progression, and those who are considered the “highrisk, high-cost” cases.

E. Mullahy (2014) identified four major areas of activities for case managers in the health insurance/managed care or payer-based practice settings. Some of these activities are applied based on the need and the situation or the job description designed by the insurance company for the case manager (Box 4-8).

F. The insurance company-based case manager may engage in activities either telephonically or face to face/on site in the health care provider organization where an enrollee is being treated.