Case management is defined as a health care process in which a professional helps a patient or client develop a plan that coordinates and integrates the support services that the patient/client needs to optimize the healthcare and psychosocial possible goals and outcomes. The case management process helps the patient and their family navigate through a complicated set of services and supports available within a benefit plan, an organization or institution, and their community. Concerning cost-effective outcome analysis, Hudon et al. found that approximately 10% of patients account for approximately 70% of all healthcare expenditures. Statistics show that 5% of emergency department patients account for 30 to 50% of emergency department visits and these high utilizing patients may unsuccessfully attempt to meet their healthcare and related needs on their own which often is ineffective, characterized by overutilization of expensive, or underutilization and uncoordinated effective health care and social services.
Case management is often a part of other healthcare activities embodied in terms such as care management, care coordination, and disease management. All these terms have overlapping definitions and identities. Case management is a fundamental element of these other activities. Care management, frequently used in the payer context, is somewhat of an umbrella term and describes a program composed of a broad set of activities and tasks that include the healthcare-related aspects of case management but also extends to a wide array of services, supports, benefits, and entitlements spanning many domains to which the patient/client may have access, including healthy lifestyle programs, recreational activities, and social enrichment programs within a benefit plan.
Care coordination also encompasses the activities and tasks included in case management but is seen in a broader programmatic context and frequently is discussed in the population health context as a means for an organization or institution pursuing population health strategies to manage the many needs of a population of patients, often by determining specific sub-groups who should receive case management services. In contrast to care management and care coordination, disease management is a narrower form of case management. It typically is case management directed at particular patient groups who all share a common diagnosis or condition. For example, patients with arthritis or patients after joint replacement surgery may be offered a discrete disease management program for a specific period. Those professionals who conduct case management are described as service brokers, service coordinators, or system navigators.
Since health care is often likened to a journey, other metaphors like travel companion, travel agent, and travel guide are used that attempt to capture not only the centrality of case management to the health care journey but also the need for navigational assistance in helping to shape the itinerary of the health care journey for the patient/client.
The components of case management are many. Hudon et al. summarize several descriptions of case management including those from the Case Management Society of America and the National Case Management Network of Canada and describe six core elements which include patient identification and eligibility determination, assessment, care planning along with goal setting, plan implementation, plan monitoring, and transition and discharge. Ahmed and Kanter, also summarize similar case management core element lists. However, case management descriptions may go beyond these six core elements and include additional activities and tasks that comprise case management.
In a literature review, Lukersmith et al. identified 79 articles that identified 22 definitions of case management, described five models, and delineated 17 key components to case management comprising 69 activities and tasks that include and build upon the six core elements. This variability in both the definition and description of case management may lead to an amorphous sense of case management in a given healthcare initiative. It may also contribute to potential role confusion and ambiguity among those who conduct case management activities and tasks. The 17 key components identified in the literature review include: case finding, establishing rapport, assessment, planning, navigation, provision of care, implementation, coordination, monitoring, evaluation, feedback, providing education and information, advocacy, supportive counseling, administration, discharge, and community service development.
Since case management is so encompassing as a concept and a set of activities and tasks in health care, there are many perspectives from which to understand and view case management. Case management may be used by health insurers/payers, hospitals, health systems, physician practices, and community health organizations. Also, case management may be directed at broad populations of patients in primary care with various chronic conditions or a more narrowly defined population of patients affected by a specific clinical circumstance or disease, such as patients with brain injury. Case management goes from the identification and engagement of patients/clients through the assessment and care planning steps and culminating in monitoring the care described in the care plan and ultimately achieving the targeted outcomes in a measurable manner. The fundamental ingredient to case management is the planning of care, which results in a care plan that essentially is the roadmap for a given patient/client to navigate through.
Issues of Concern
Case management encompasses a wide range of activities; therefore, it is challenging to define case management as a discrete intervention precisely. Besides, the definitional variability of case management and the clinical setting in which case management occurs is also ample. Lukersmith et al., in their review of 79 articles, identified a variety of service sectors and service settings that utilize case management. The service sectors include health, social, correctional, vocational, veterans, and legal sectors. The service settings include public, private, and non-governmental organizations that could be further stratified by the number of resources and support.
Depending on the service sector and the service setting, case management occurs across a continuum of involvement ranging from a relatively brief episodic type interaction that might be offered to a patient during and after an inpatient orthopedic procedure to a much more holistic, longitudinal interaction as might occur in the context of a patient with a severe mental health disorder who is served by a community-based organization over many years.
The evolving and expansive nature of what to include in case management has led to variability definitions and variability in what constitutes a case management intervention. This ambiguity is often observable in the literature. Hudon et al. conducted a systematic analysis involving 21 articles and 89 other related documents and identified at least five different service delivery configurations classified as case management in the healthcare setting. Lambert et al. characterize current literature on case management as somewhat of a black box, and propose that case management is so complex and variable in practice and definition, that it should be considered a process that unfolds that links interconnected actions within a complicated, adaptive health care system.
The case management process occurs over time and in the context of a relationship among the patient/client, the case manager, and the various healthcare providers and organizations that interact and provide services and supports. Case management's process unfolds as the six core elements to case management are operationalized for a given patient/client in their specific clinical context. The six core elements are included in the long lists of the 17 components identified by Lukersmith et al. and are described below.
- Patient identification and eligibility determination: Case finding describes a process involving activities focused upon the identification of patients/clients not currently receiving case management services. Establishing rapport consists of building an interpersonal connection between the case manager and the patient/client.
- Assessment: Assessment refers to construct a detailed, comprehensive understanding of the patient/client which includes, their healthcare and social needs, their capabilities, and the resources they have access to in their family and community.
- Care planning along with goal setting: Planning encompasses the steps necessary to build a care plan that defines treatment goals, tasks and actions needed to move towards those goals, access to specific services and supports required to achieve the stated goals and final the identification of targeted outcomes that are specific to that the patient/client. Navigation encompasses the part of the case management process where the case manager helps guide the patient/client to services and supports recognizing and working to remove barriers that can either be anticipated or those that unexpectedly arise. Provision of care occurs when the case manager is also part of the treatment team as might happen in the mental health setting. For example, where the patient' s/client's case manager might also be part of the therapy team providing counseling and skills training.
- Plan implementation: Implementation, is the part of the case management program where the plan of care with its varied activities and tasks, is set in motion. Coordination is related to navigation but is broader and refers to the myriad of facilitations that must occur between and among care providers, service settings, organizations, and institutions with the patient/client also being the focus and at the center of this component of the case management process.
- Plan monitoring: Monitoring occurs throughout the entire process and is related to seeking ongoing feedback and conducting follow-up as necessary to how the plan of care is being implemented and producing results. Evaluation is closely related to monitoring but occurs at specific milestones during the case management process to formally determine if the care plan helps the patient/client achieve progress towards goals and outcomes. Feedback as a component of case management involves communication back to service providers about their services' effectiveness. It supports in assisting the patient/client in making progress as defined in the plan of care. Providing education and information encompasses helping the patient/client and their family/support system develop a deeper understanding of relevant health and health care topics. Advocacy refers to activities directed at empowering the patient/client to pursue services and supports and related accommodations and proper entitlements to their circumstances. Supportive counseling describes the case manager's effort to consistently provide encouragement and emotional support as the care plan unfolds. Administration encompasses the paperwork, report writing, and data gathering and analysis that are part and parcel of the modern health care system.
- Transition and discharge: Transition describes the process when a client is prepared to move across the healthcare continuum, depending on the patient's health and the need for services. The client can be moved home or transferred to another facility for further care. Discharge represents the case management process component in which the patient's/client's case reaches the point of closure, goals are met, and the patient's needs warrant disengagement with the case management process. Finally, community service development occurs when the case management process uncovers a need or service gap within a given community. Then the case manager catalyzes efforts to create that service or support to fill that gap.
Case management is about helping patients coordinate and navigate through their health care in a cost-effective manner. Hudon et al. identified a set of 5 patient-centric positive outcomes that include improvement in self-management skills, care plan adherence, satisfaction, self-reported health status, and perceived quality of life. They also identified two system-level outcomes: a reduction in overuse and cost and improvement in measured quality of care. A year earlier in a related article, Hudon et al. described a list of positive outcomes that spanned patient and system-oriented parameters which included: health status, functional status, patient satisfaction, self-management, emergency department visits, clinic visits, hospital admissions, hospital length of stay, and inpatient costs.
In this review, positive outcomes were most likely to be documented in case management interventions that included high-intensity interventions (i.e., case management described by small case-loads, face-to-face contacts were frequent and the first assessment occurred in person) were offered to the patients/clients as well as when multi-disciplinary and inter-organizational plans of care where part of the intervention as well.
The case management process fundamentally assists a specific patient/client in coordinating and navigating through their healthcare journey. The key to this assistance is the construction and implementation of a relevant and feasible plan of care that, when followed, will help the patient move towards their stated goals and positive health outcomes with an optimal level of functional capability, wellness, and self-management. Case management will ultimately improve the quality of life for the client.
Nursing, Allied Health, and Interprofessional Team Interventions
Case management, owing to its focus on coordination, is inherently rooted in multi-disciplinary communication and teamwork. An effective case manager must facilitate communication among various disciplines to develop a plan of care that is inclusive of the many fields that are typically involved in the care of a patient. It is especially important in those patients/clients with chronic conditions or who find themselves in circumstances where they frequently utilize healthcare services. The case manager must interact with a wide range of patients/clients from various backgrounds, have a wide range of capabilities, and access varying family and community support levels.
Nurses and social workers are often seen as ideal for conducting case management due to their clinical experience and communication and teamwork training. Specific clinical areas may also include other related professionals. They might bring expertise to the case management process such as occupational therapists in the rehabilitation setting, or psychologists in the behavioral health setting. Clinical experience is uniformly recognized as useful in the training process towards becoming an effective case manager. Most agree that a baccalaureate degree in nursing is an expected minimum with a master's degree preferred and seen as ideal.