Overview of Case Management

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Overview of Case Management

• Susan Chapman, PhD, RN
• N 226 Guest Lecturer
• February 12, 2003

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What is Case Management?

• A process that enhances continuity and
  appropriateness of care and setting
• Coordination across care settings
• Involves cross-disciplinary decision making
• Involves family members/support network
• Requires specialized knowledge

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History of Case Management

• Public health nursing-transition to home
• 1970s - origins in Workers Comp and mental
  health
• 1985 - managed care, high cost cases
• 1995 - assist in navigating health care system
• Disease management - focus on single
  disease/condition
• J. Ebert. Public Health Nursing,. Vol 18(5) 2001

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What are the Goals of Case Management?

• Coordinate complex illnesses/conditions
• Control costs/resources
• Decrease length of stay
• Avoid hospitalization
• Increase patient/family satisfaction
• Improve outcomes
• Provide comfort measures
• Overall to improve quality of care

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Why Nurses for Case Managers?

• Nursing process is involved
• Critical thinking/decision making
• Clinical skills
• Teaching skills
• Communication skills
• Ability to work with multiple disciplines
• Cost effective
• Knowledge of spectrum of health services

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Critical Pathways/Clinical Guidelines

• Millman Robertson, others
• Actuarially- based algorithms predicting/proscribi
  ng care pathway
• Care Maps - used in care settings
• Specific criteria, processes
• Local home grown or national
• Governments role in creating clinical guidelines

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What is the Evidence?

• Criteria for success focused on cost savings
• Satisfaction measures indicate some patients and
  families are helped
• Some evidence of improved outcomes
• decreased rate of hospitalization
• decrease in physician visits
• stable or improved clinical indicators
• Need more research on outcomes and quality

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Stories from the Front Lines of Case Management

• Case management in a managed care company
• Focused on high cost/catastrophic cases
• Role evolved to coordination and navigating the
  system
• Provide link between various practitioners
• Allowed flexible interpretation of benefits
• Frequent contact/family support

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Ethical Issues in Case Management

• Is case management a form of rationing?
• Is patient choice denied?
• Is population more important than the individual?
• Confidentiality issues
• Competing loyalties (employer, patient)

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Disease Management and Future Directions

• Focus on single diseases/systems, chronic illness
• Diabetes
• CHF
• COPD
• Goal to avoid hospitalization
• Group treatment/visits/classes
• Kaiser Permanente is innovative in care
  management, e.g., COPD program

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For More Information

• Case Management Resource Guide
• cmrg.com
• Case Management Society of America
• cmsa.org
• Health Plan web sites
• Nursing organizations
• Resources for specific diseases/conditions