A. Today, in the health care environment, there is an increasing focus on quality and quality-of-care outcomes coupled with an even more intense focus on effectiveness and efficiency of the care received.

B. As case management roles transform in response to health care changes, many case managers find that some of the traditional goals of case management (CM) seem incongruent with expanding responsibilities.

C. In reality, case managers are trying to meet the goals of different customers at the same time while ensuring that patient involvement and empowerment leads to supported patient self-management.

D. Care coordination makes it possible to achieve balance in both the patient-centered and system-centered goals of case management. Recognizing this begins with acknowledging the complexity of a case manager’s job and understanding there is a need for tools (e.g., road maps, reports) to support the successful resolution of identified patient needs (e.g., barriers to care, health education).

E. Consider that a case manager must understand the current health care environment and be aware of ongoing transformation at multiple levels (e.g., individual, organizational). Case managers not only need clinical skills and knowledge but also must master business skills and knowledge.

F. Today, the consumers of case management services demand collaborative, well-defined, and managed plans of care.

G. This chapter provides an overview of case management plan design, reviews tools available to assist in evidence-based case management plan development, and discusses strategies for developing comprehensive, high-quality, multidisciplinary, patient-centered plans of care.

A. Accountable Care Organization (ACO)—Groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time while avoiding unnecessary duplication of services and preventing medical errors (Centers for Medicare and Medicaid Services [CMS], 2015).

B. Algorithm—A systematic process consisting of an ordered sequence of steps, each step depending on the outcome of the previous one; in clinical management a protocol (MediLexicon.com, 2015) that guides step-by-step assessments and interventions. Algorithms are generally most useful for high-risk groups as they are known for their specificity (very specific) and generally do not allow for provider/patient flexibility. Often utilized to manage a specific process, control care practices, or address an individual problem. Algorithms may incorporate research methodology to measure cause and effect (Wojner, 2001).

C. Care coordination—The deliberative 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 activities and is often managed by the exchange of information among participants responsible for different aspects of care (McDonald et al., 2014).

D. Case management care plan—A comprehensive plan that includes a statement of problems/needs determined upon assessment, strategies to address the problems/needs, and measurable goals to demonstrate resolution based upon the problem/need, the time frame, the resources available, and the desires/motivation of the client (Case Management Society of America [CMSA], 2010).

E. Clinical pathway—A structured, interdisciplinary care management plan designed to support the implementation of specific clinical guidelines and protocols. Clinical pathways are computational maps or algorithms and are one of the primary tools used to manage health care quality by focusing on the standardization of care processes. Pathways are used to guide the various health care team members on the usual treatment patterns related to common diagnoses, conditions, and/or procedures.

F. Clinical practice guidelines (CPGs)—Systematically developed statements designed to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances (Institute of Medicine, 2011).

G. Evidence-based medicine—The definition of evidence-based medicine (EBM) provided in 1996 by Sackett, Rosenburg, Gray, Haynes, and Richardson continues to be relied upon today. EBM is the “integration of the best research evidence with clinical expertise and patient values to make clinical decisions.” The evidence being referred to is “patient centered, clinically relevant research found in the medical literature on diagnostic tests, treatment techniques, preventive programs, and prognostic markers” (Steves & Hootman, 2004). EBM injects contemporary research findings into day-to-day clinical practice and patient care.

H. Patient Protection and Affordable Care Act (PPACA or ACA)—A U.S. Federal Statute signed into law on March 23, 2010. Together with the Health Care and Education Reconciliation Act amendment, it represents the most significant regulatory overhaul of the US health care system since the passage of Medicare and Medicaid in 1965. Enacted to increase the quality and affordability of health insurance, lower the uninsured rate by expanding public and private insurance coverage, and reduce the costs of health care for individuals and the government (CMS, 2015).

I. Protocol—Guidelines designed to address specific therapeutic interventions for a given clinical problem. Protocols are less specific than algorithms and do allow for minimal provider flexibility via treatment options. They are multifaceted and therefore can be used to drive practice for more than one discipline. Like algorithms, they may and most often do incorporate research methodology to measure cause and effect. Guidelines are based on examination of current evidence within the paradigm of evidence-based medicine and usually include consensus statements on best practices in health care (Institute of Medicine, 2011; Wojner, 2001).

J. Evidence-based Clinical Decision Support Criteria—Impartial, evidence-based tools used as a lexicon to evaluate the decisions about the appropriateness and quality of care that support integrated care
management and utilization management (UM) approaches to evaluate patient care and services (Mitus, 2008).

A. The Case Management Society of America (CMSA) describes in its standards of practice for case management that case management practice extends across all health care settings, including payer, provider, government, employer, community, and clinic or doctor’s office, and that case managers use a variety of tools to ensure effective practice and delivery of safe and quality patient care (CMSA, 2010).

B. This chapter describes various plans, pathways, and protocols, which support the case management roles, functions, and activities described in the CMSA standards including the case management process.

C. According to CMSA, the resource and resource utilization practice standard explains that case managers should incorporate factors related to quality, safety, access to care, and cost-effectiveness in assessing, monitoring, and evaluating resources for the client’s care (CMSA, 2010).

D. CMSA standards of practice for case management also state that case management plans should address anticipated resources needed by the client, but case managers must be cognizant of the benefits (health insurance plan) available to provide for these resources (CMSA, 2010).

E. Alternate funding sources serve as added means to secure the resources a client needs.

F. CMSA recommends that resources allocation and consumption should be based on the client’s needs as documented in the case management plan of care, evidence-based practice guidelines, care goals, and effective and efficient use of health care and financial resources (CMSA, 2010).

G. This chapter addresses case management practice, which requires knowledge of and proficiency in the following practice standards: Assessment, Problem/Opportunity Identification, Planning, Monitoring, Outcomes, and Facilitation/Coordination and Collaboration.

A. Historically, case management was considered a social worker function due to early efforts of settlement houses of the late 1800s and early 1900s. Residents and volunteers of early settlement houses helped create and foster new organizations and social welfare programs, some of which continue to the present time. Settlements were action oriented where programs and services were added as neighborhood needs were discovered. For example, social workers assisted people in the settlements in addressing poverty and health issues in an effort to enhance their quality of life.

B. In the late 1980s, case management care planning became more aligned as a nursing responsibility due to legislative and regulatory requirements. Conceptualizing case management as either social work or nursing is inaccurate; doing so does not effectively capture the spirit of the intervention, nor is it inclusive of an interdisciplinary care team approach.

C. Case managers understand that care planning must include all members of the health care team, especially the patient. Because planning is an
essential part of the case manager’s work, it has been highlighted as a component of the case management process and identified as a practice standard.

D. Case management care plans are tools to define practice and as guides for patient care activities (Tahan, 2002). Plans should be patient-specific, action-oriented, and time-defined.

E. Tahan (2002) identified a number of characteristics of a case management plans that are helpful for case managers to be aware of and consider when developing and implement case management plans for their patients (Box 21-1).

F. An effective case management plan is a specific document (or electronic equivalent) that delineates

G. The uses of a case management plan include