A. History of Case Management

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

A. ADLs—Activities of Daily Living include activities carried out for personal hygiene and health.

B. Assessment—The process of collecting in-depth information about a person’s health and functioning to identify needs in order to develop a comprehensive case management plan that will address those needs. In addition to client contact, information gathered should be from all relevant sources.

C. Autonomy—A form of personal liberty in which the client holds the right and freedom to make decisions regarding his or her own treatment and course of action and take control for his or her health, fostering independence and self-determination.

D. Case Manager—A health care professional who is responsible for applying the case management process in the care of individuals with health-related needs (e.g., biopsychosocial, physical, functional, cognitive, emotional, financial, etc.) with the goal of maximizing their wellness, autonomy, safety, appropriate use of resources, and maintenance of health condition. The case manager applies the process in collaboration with the patient/family or caregiver and other health care providers.

E. Catastrophic Case—Any medical condition that has heightened medical, social, financial, and functional consequences.

F. Continuum of Care—The continuum of care matches ongoing needs of the individuals being served by the case management process with the appropriate level and type of health, medical, financial, legal,
and psychosocial care for services within a setting or across multiple settings.

G. Coordination—The process of organizing, securing, integrating, and modifying the resources necessary to accomplish the goals set forth in the case management plan.

H. Developmental Disability—Any mental and/or physical disability that has an onset before age 22 and may continue indefinitely. It can limit major life activities.

I. Disability Case Management—A process of managing occupational and nonoccupational health conditions with the goal of returning the disabled employee to health, productivity, and employment.

J. Discharge Planning—The process of assessing an individual’s health care needs upon discharge from a health care facility or agency and ensuring that the necessary services are in place before discharge.

K. Disease Management—A system of coordinated health care intervention and communication aimed at populations with chronic conditions in which the patient’s self-care efforts and day-to-day living are significantly affected.

L. Implementation—The process of executing specific case management activities and/or interventions that will lead to accomplishing the goals identified in the case management plan.

M. Integrated Delivery System (IDS)—A single organization, or group of affiliated organizations, providing a wide spectrum of ambulatory and tertiary care and services. Care may also be provided across various settings of the health care continuum.

N. Intellectual Disability—Refers to the below-average general intellectual functioning manifested during the developmental period and existing concurrently with impairment in adaptive behavior. This was previously referred to as mental retardation.

O. Monitoring—The ongoing process of gathering sufficient information from all relevant sources regarding the effectiveness of the case management plan implemented.

P. Outcome Indicators—Measures of quality and cost of care. Metrics used to examine and evaluate the results of the care delivered.

Q. Outcomes Management—The use of information and knowledge gained from outcomes monitoring to achieve optimal patient outcomes through improved clinical decision making and service delivery.

R. Outcomes Measurement—The systematic, quantitative observation, at a point in time, of outcome indicators.

S. Planning—The process of determining specific needs, goals, and actions designed to meet the client’s needs as identified through the assessment process.

T. Primary Care—A process of assessing, planning, coordinating, and providing health care from a consistent practitioner who serves as the central point of contact for all other practitioners.

U. Provider—A person, facility, or agency that provides health care services.

V. Social Work—Social work is a practice-based profession and an academic discipline that promotes social change and development, social cohesion, and the empowerment and liberation of people. Principles of social justice, human rights, collective responsibility, and respect for diversity are central to social work. Underpinned by theories of
social work, social sciences, humanities, and indigenous knowledge, social work engages people and structures to address life challenges and enhance well-being (International Federation of Social Workers, 2014). Social workers usually collaborate with case managers and other members of the interdisciplinary health care team in the care of individuals, especially in the coordination of needed community resources and health and human services.

W. Standards of Practice—Statements of acceptable level of performance or expectation for professional intervention or behavior associated with a professional practice.

X. Transition Planning—The process case managers apply to ensure that appropriate resources and services are provided to patients and that these services are provided in the most appropriate setting or level of care.

Y. Utilization Review—A mechanism used by some insurers and employers to evaluate health care on the basis of medical appropriateness, necessity, and quality. Typically, this is used to determine access to an insurance benefit.

Z. Vocational Rehabilitation—A process whereby a skilled professional utilizes the case management process to address the medical and vocational services necessary to facilitate a disabled individual’s expedient return to suitable employment.

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. It also explains that the role of a case manager may be assumed by individuals from a variety of professional disciplines including nursing, social work, and vocational rehabilitation counseling.

B. It is known that the roots of case management are about a century old. The practice, however, has evolved over time and gained increased attention based on the sociopolitical dynamics of the health care environment in the United States. Understanding the historical background of this practice by case managers is essential for professional standing in society and the health care industry. The CMSA’s standards of practice also evolved over time and have been affected by the changes in the health care environment, which have occurred over the past three decades.

C. This chapter contains historical background, which outlines the underpinnings of modern case management practice. The CMSA Standards of Practice highlights pertinent to this chapter include the following: Philosophy and Guiding Principles, Definition of Case Management, and Client Selection Process for Case Management Standard.

A. Cost of health care—Increasing amount of the gross domestic product (GDP) that goes toward health care. In the early 1990s, one-seventh of the U.S. GDP went toward the payment for health care (Cohen, 1996).
The U.S. health care spending grew 3.6% in 2013, reaching $2.9 trillion or $9,255 per person. As a share of the nation’s GDP, health spending accounted for 17.4% (Centers for Medicare and Medicaid Services, 2015).

B. Increasing consumerism secondary to more accessible information, increased expectations of patient involvement on the part of health plans, shift of health care onto financing onto consumers, and negative repercussions of managed care.

C. New emphasis on evidence-based health care reimbursement by health plans.

D. Information explosion through expansive use of electronic communication technology, digital tools, and social media.