Case management

Case management

Case management is an area of practice within several healthcare professions. Most case managers are nurses or social workers.

The term case management is also used to refer to dispute resolution systems which provide court or tribunal officials with closer administrative control over the litigation process than is traditionally associated with common law litigation.Boulle, L. (2005). Mediation: Principles Process Practice. 2nd Edition. Queensland, Australia. LexisNexis Butterworths.]

Case management in health care

The Case Management Society of America defines case management as:

:"a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes." [cite web | author=Case Management Society of America | title=Definition of Case Management | url= | date= | accessdate=2007-01-13]

One does not have to be a nurse to function as a case manager. Most social workers have no clinical component in their background yet function as case managers. Discharge planning is more of a social services discipline; the reason that most hospitals utilize nurses as a case manager is because of the need for utilization review. From a bird's eye view, the CM position is broken down into a few components. 3/4 of the workday is spent doing utilization review, and the other quarter is actual discharge planning.

Most nurse case managers work in hospitals or at health maintenance organizations; some function as independent consultants.

Case management focuses on delivering personalized services to patients to improve their care, and involves four steps::1) Screening to find appropriate patients:2) Planning & delivery of care:3) Evaluation of results for each patient & adjustment of the care plan:4) Evaluation of overall program effectiveness & adjustment of the programWilliam F. Bluhm, "Group Insurance: Fourth Edition," Actex Publications, Inc., 2003 ISBN 1-56698-448-3]

In the context of a health insurer or health plan it is defined as:

A method of managing the provision of health care to members with high-cost medical conditions. The goal is to coordinate the care so as to both improve continuity and quality of care and lower costs.Peter R. Koongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001 ISBN 0-8342-1726-0]

Specific types of case management programs include catastrophic or large claim management programs, maternity case management programs, and transitional care management programs.

Case management functions

Health insurer and HMO setting

Case managers working for health insurers and HMOs typically do the following::1) Check benefits available;:2) Negotiate rates with providers who are not part of the plan's network;:3) Recommend coverage exceptions where appropriate;:4) Coordinate referrals to specialists;:5) Arrange for special services;:6) Coordinate insured services with any available community services; and:7) Coordinate claims with other benefit plans.

By identifying patients with potentially catastrophic illnesses, contacting them and actively coordinating their care, plans can reduce expenses and improve the medical care they receive. Examples include identifying high-risk pregnancies in order to ensure appropriate pre-natal care and watching for dialysis claims to identify patients are risk of end-stage renal disease. The amount of involvement an insurer can have in managing high cost cases depends on the structure of the benefit plan. In a tightly managed plan case management may be integral to the benefits program. In less tightly managed plan, participation in a case management program is often voluntary for patients.

Health care provider setting

Case managers working for health care providers typically do the following::1) Verify coverage & benefits with the health insurers to ensure the provider is appropriately paid;:2) Coordinate the services associated with discharge or return home;:3) Provide patient education;:4) Provide post-care follow-up; and:5) Coordinate services with other health care providers.

Employer setting

Case managers working for employers typically do the following::1) Verify medical reasons for employee absences;:2) Follow up after absences from work due to poor health;:3) Provide health education;:4) Assist employees with chronic illnesses; and:5) Provide on-site wellness programs.

Hospital Case Management

The American Case Management Association (ACMA), a non-profit professional membership organization supporting the practice of hospital case management through education, networking, publications, benchmarking and research, defines Hospital/Health System Case Management as:

"“…A collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient's right to self determination."

Hospital Case Managers are professionals in the hospital setting who ensure that patients are admitted and transitioned to the appropriate level of care, have an effective plan of care and are receiving prescribed treatment, and have an advocate for services and plans needed during and after their stay. Case Managers concurrently plan for transitions of care, discharge and often post discharge follow up. Case Managers often coordinate/communicate with the patient and family, physician(s), funding sources (i.e. insurance, Medicare), and community resources that provide services the patient may need, such as rehabilitation facilities or providers of medical equipment. Through this coordination, hospital case managers’ goals are to ensure both optimal patient and hospital outcomes including quality of care, efficient resource utilization and reimbursement for services. Hospital Case Management is a collaborative practice, consisting primarily of Nurse and Social Work professionals working in collaboration with physicians and other members of the healthcare team.

Case Managers’ Role

A Case Manager’s responsibilities include the following functions:

•Advocacy & Education – ensuring the patient has an advocate for needed services and any needed education.

•Clinical Care Coordination/Facilitation – coordinating multiple aspects of care to ensure the patient progresses.

•Continuity/Transition Management – transitioning of the patient to the appropriate level of care needed.

•Utilization/Financial Management – managing resource utilization and reimbursement for services.

•Performance & Outcomes Management – monitoring, and if needed, intervening to achieve desired goals and outcomes for both the patient and the hospital.

•Psychosocial Management – assessing and addressing psychosocial needs including individual, familial, environmental, etc.

•Research & Practice Development – Identifying practice improvements and using evidence based data to influence needed practice changes .

Hospital Case Manager Education and Certification

To be a Case Manager requires experience in the hospital setting, typically as a nurse or a social worker. Additional skills specific to case management are learned in the role. Advanced certification is available to Hospital Case Managers through the Accredited Case Manager™ (ACM) Certification, offered by ACMA. The ACM™ Certification is the only certification that is specifically designed to validate an individual’s competency in hospital case management practice, and is offered to both Nurse and Social Work Case Managers.

The ACM™ Certification requires professionals to apply, demonstrate two years of hospital case management experience and licensure as a nurse or social worker, and to sit for and pass an examination. The exam consists of two components. The first section contains core case management questions that test the knowledge of Case Managers working in a hospital/health system. The second component is comprised of clinical simulations, which test the application of case management knowledge to simulated practice scenarios. Successful completion of the ACM™ Certification requires passing both parts of the exam, and earns the successful application the ACM credential. This credential must be renewed every four years through demonstrating the required hours of continuing education.

American Case Management Association

ACMA is the association solely for Hospital Case Management professionals, and currently consists of more than 2,000 members, and is represented by 18 state chapters nationwide. ACMA provides hospital-focused education and networking for Case Managers – including nurses, social workers, physicians, administrators and other health care professionals.

Case Management and the regulation of mediation

Case management refers to systems in which court or tribunal officials assume closer administrative control over the litigation process than is traditionally associated with common law litigation. The Assisted Dispute Resolution program was introduced into the Federal Court in 1990. This was instigated after a number of cases failed to reach resolutions after several directional hearings. The parties had still not isolated the issues requiring determination. Judges could then refer the parties to a court registrar for mediation. The following section was introduced into the Federal Court of Australia Act in 1991:

‘Subject to the Rules of Court, the Court may, with the consent of the parties to proceedings in the Court, by order refer the proceedings, or any part of them or any matter arising out of them to a mediator or an arbitrator for mediation or arbitration as the case may be….’Mediation as an alternative dispute resolution (ADR) method is designed to avoid resorting to formal court-based adjudication and is now also being applied to criminal matters. Traditional theories of criminal justice view the matter as one between the offender and the state. [Sarre, R. and Earle, K. (2004). Restorative Justice in Key Issues in Criminal Justice Sarre R, and Tomaino, J. (eds) Key Issues in Criminal Justice, Adelaide: Australian Humanities Press]

It was not necessary to have the parties consent to the mediation process. The judge could direct the mediation. Case management was designed to identify and define issues in dispute and to reduce delays, costs and unnecessary pre-trial activities.

It is now becoming widely accepted and even institutionalised and promoted by governments, that ‘what was born of resistance and opposition to the formal justice system has been extensively integrated and co-opted into the system’. [Astor, H & Chinkin, C. M. (2nd Edition, 2002). Dispute Resolution in Australia. Sydney Australia.. LexisNexis Butterworths]


ee also

* Nursing process
* Telephonic nursing
* Utilization review
* Medical case management

External links

* [ Commission for Case Manager Certification]
* [ Case Management Society of America]
* [ American Case Management Association]
* [ Case Management resources]
* [ "On the Case"] from

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