Case Management
The forces in health care today have made it necessary to develop care delivery systems that go beyond the industrial model, which emphasized task completion and outputs, to integrated systems that include mechanisms to define the links between nursing care and outcomes and to demonstrate costeffectiveness. In evaluating care delivery systems, many institutions have implemented the case management model because it helps organize care around the client and is in concert with interdisciplinary and intradisciplinary differentiated practice. Because this model addresses many concerns previously identified, it is discussed here is some depth. Entire texts have been written about case management, however, and you are encouraged to refer to these and other sources for further information (Powell, 2000a and 2000b).
Case management is not a new concept. Nurses and members of other disciplines have been providing case management for clients for many years. Community public health programs have had case management services since the 1900s (Lyon, 1993). Behavioral health nurses have been using many of the concepts in the community since the 1960s. Case management received more attention from other areas of health care, including acute care settings, when insurance companies began using the model. In recent years, it became one of the most frequently used care models in the country (AHA, 1990). Now the model is not only well recognized but also universally accepted (Powell, 2000a).
Case management is a care delivery model focused on the client that promotes continuity and cost-effectiveness, recognizes the contributions of the members of the interdisciplinary team, and allows for differentiation of practice within the nursing profession. There are many definitions of case management. Bower (1992) described case management as a “paradoxically simple yet complex concept” (p. 3). Simply stated, case management refers to “patient focused strategies to coordinate care” (Bower, 1992, p. 2). Case management has also been defined as “an approach that focuses on the coordination, integration, and direct delivery of patient services, and places internal controls on the resources used for care” (Cohen & Cesta, 1993). Gerber (2001) combines the definition of the Case Management Society of America (CMSA), and Smith’s definition to provide the following descriptive definition of case management:
Nursing case management can be defined as the application of the collaborative and interdisciplinary case management process by professional nurses to promote the delivery of high quality, holistic, cost-effective health and illness care to individuals and groups within communities and complex organizational systems through patient advocacy, communication, and effective management of available resources. (p. 693)
The purposes of case management are to ensure cost-effectiveness, quality, and continuity of care.
Case management is often confused with other concepts, including managed care, because the terms are frequently used interchangeably, and because the historical development is similar (Cohen & Cesta, 1993). Refer to Chapter 19 for an in-depth discussion of managed care plans and financing. The entity with the most risk for expensive care and treatment of the client typically provides case management services. Managed care providers or insurance companies may
provide case management services in an attempt to promote wellness and prevent hospitalization, because hospital care is usually the most costly kind of care. The hospital may also provide case management services once clients are admitted, because insurance pays only a designated amount of money, either per day or for the entire period of hospitalization, and the incentive is for hospitals to provide care as cost-effectively as possible.
Case management can be provided in a variety of settings. Lyon (1993) delineates three categories of case management in health-care settings: hospital-based case management, case management across the healthcare continuum, and community case management.