Issue Brief

Case Management
April 2003

Prepared by:
M. Ryan Barker, Policy Associate
Kathryn DeForest, Program Officer
Leslie Reed, Director of Policy Studies
MFH Policy Group

Issue Brief:
Case Management

Introduction
The Missouri Foundation for Health (MFH) has received many grant requests that
include case management as a service component of the proposed program. At the
March 2003 meeting of the Program and Grants and the Program Review Committees,
information about case management was requested. As a result, the MFH Policy group
has compiled this issue brief to provide the following:

Definitions from the field

Significant developments

Diagrams of case management and its role in health care

Examples of successful programs

Definitions
Broadly, case managers describe their work as: Doing whatever it takes, with whatever
youve got, for as long as it takes, to get the job done.1 The American Case
Management Association promotes this definition: Case management in hospital/health
care systems is 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 patients right to self determination.2

Case management may target individuals or families from defined populations such as
children, refugees or those with a specific disease. It enlists varying degrees of the
available resources from a range of service providers to meet complex needs. The
process of case management:

defines the problem,

identifies the resources needed,

coordinates engagement of appropriate services,

ensures that the resources complement each other and

monitors the coordination of services to meet the needs of the client.

Significant Developments
Throughout the twentieth century case management grew in recognition and acceptance
within the public health sector of the United States. The deinstitutionalization of disabled
populations in the 1960s resulted in increased community-based case management
services that now function as a key element of treatment.3 The 1990s witnessed the
formation of national and local case management associations through which
certification programs in case management emerged.4
Since the year 2000, states have established 3,000 regulations and the Federal
government has created 600 requirements to govern the intricate set of case
management activities involved in providing resources for people confronted with
complex health, legal or social problems.5 Several studies have shown that case
management can be used to reduce or limit the cost of health care and the inappropriate
use of health services for enrolled populations.6 Attesting to its value and effectiveness,
Medicaid and Medicare reimburse for case management services under certain
circumstances.7

Diagrams of Case Management

From staff conversations about how to define and categorize the many elements that
make up case management two diagrams emerged. The first attempts to place case
management in context with the health care system. The second provides a schematic
for the complex set of activities that comprises case management.

Diagram #1, Linkage of Health Care and Case Management, shows possible points
of entry into health case management (through the health care system or through the

social services system). It proposes that referral is the linkage between case
management and health care. This process results in improved health status. External
factors (environment, heredity and behavior) may negatively impact health, reinitiating
the cycle of care.

Linkage of Health Care and Case Management, Diagram #1

Diagram #2, Overview of Health Case Management, maps the process of case
management beginning with referral. Through assessment, one of four support types is
selected according to the nature of the problem. Case managers then choose among a
range of interventions dependent on both the need of the patient and the capacity of the
particular case management program. The case management process (as in Diagram
#1) results in improved health status.

Overview of Health Case Management, Diagram #2

Support Type
Single Visit
Goal: Simple
Resolution

Referral

Assessment

Limited Contact

Individual Case
Manager
or
Team Case
Management

Goal: Address
most critical
problems
Defined Duration
Goal: Establish
Equilibrium
On-Going Care
Goal: Maintain
Stability

Intervention
Service
Enhancement:
Supports Health
Intervention
Targeted Case
Management:
Involves major
sources of support

Comprehensive
Case Management:
Involves all known
sources of care

Hybrid Models

Improved
Health
Status

Case Management Programs

Case management occurs in a wide range of settings including health clinics, hospitals,
mental health organizations, senior care facilities, etc. Three examples of successful
health-related case management programs follow; each traces the path of a patient
through Diagrams #1 and #2.

Community Health Clinic of Joplin (Missouri)

The Missouri Foundation for Health awarded a grant to the
Community Health Clinic of Joplin in November of 2002. The
purpose of this grant was to hire two medical social workers to
provide case management services for patients. These case
managers initially verify the indigent status of those seeking
services from the clinic. Eligible individuals then receive free
medical treatment from volunteer doctors, dentists and
pharmaceutical staff. After receiving care for their immediate
medical need, patients are sent back to the case managers
(Referral) who work to ensure that basic needs are being met
(Assessment). Many who attend this clinic are so
impoverished that basic lacks in food, clean water and medical
supplies lead to their illnesses, or significantly impede their
recovery. The social workers link individuals and families to
community resources in order to improve their health status
and prevent further health complications. Often the needed
interventions are accomplished through a single interaction
with a case manager (Support Type). However, sometimes
follow-up or on-going contact may be necessary to ensure a
positive health outcome (Support Type). The services offered
by these case managers support and enhance the medical
treatment provided by the clinics doctors (Intervention).8

Meet the Smith Family

Mrs. Smith brings her 10year-old son, Jack, to the
Community Health Clinic
because of his stomach
cramps and diarrhea. An
initial screening by a case
manager determines the
familys eligibility for services.
A doctors exam results in the
diagnosis of round worms.
While the prescribed
medication will solve the
immediate problem, the
doctor is concerned about
reinfection because the
family does not have access
to clean drinking water.
The Smith family is referred
to one of the case managers
who meets with them and
connects them to a
community resource where
the family can receive free
bottled water.
This single encounter with
the case manager supports
the doctors health
intervention and supplies the
family with a permanent
solution for their immediate
need.

Senior Links to Independent Living (California)

Meet Betty
Betty is a 68-year-old female
living by herself in Long Beach.
About a year ago Betty fell and
was hospitalized with a broken
hip.

In 1998, the City of Long Beach Department of Health and

Human Services established the Senior Links to
Independent Living program for residents 55 years or older.
The goal of the program is to maximize the ability of at-risk
Long Beach seniors to maintain independent living in a safe

She has no family locally, and

her neighbors are concerned
about her well-being. She
previously spent time with
friends at the local community
center, but since the accident
she is no longer able to drive.
The neighbors call Adult
Protective Services who make
a referral to Senior Links.

and healthy environment.9 A three-part approach including

Program staff visit and find

Betty in good physical health,
but she reports being lonely
and depressed. The case
managers link Betty to local
transportation services so she
can resume her visits to the
senior center.

consisting of a public health nurse and a social worker

They also connect her with a

primary care physician to
monitor her physical as well as
mental health. The case
managers employ a targeted
case management intervention
to address Bettys health
needs.

and a primary care provider. This short-term, targeted case

community education, a telephone resource line and case

management services facilitates the achievement of this goal.
Community agencies such as the Citys Senior Police
Partners, senior centers, mental health agencies, and Adult
Protective Services make the initial referrals to the case
management component of Senior Links (Referral). A team
conduct an initial assessment with the senior and his or her
family (Assessment), and provide up to 6 months of case
management (Support Type). The services offered include
the creation of a needs-based plan, linkages to health and
community services and connections between the senior
management (Intervention) stabilizes the immediate
situation and preserves the health and independence of the
senior.10

Boston Health Care for the Homeless Program (Massachusetts)

The Boston Health Care for the Homeless Program

Meet Sam

(BHCHP) is a service delivery model that integrates

Sam, a 35-year-old man, is

homeless. He prefers not sleeping
in the shelters and prides himself
on his fierce independence. He
lives by the motto of Trust No
One.

hospital-based primary and specialty care with direct care

services at over 70 shelter and outreach sites in
metropolitan Boston.11 Staff at these service organizations
refer homeless individuals into BHCHP (Referral). Once a
new client enters the program, a team of doctors, nurse
practitioners, physician assistants, nurses and social
workers assesses the individuals needs (Assessment)
and provides on-going monitoring and care
(Support Type). BHCHP uses comprehensive case
management (Intervention): (1) to resolve critical health
issues through linkages to appropriate health care
providers and (2) to maintain stability through connections
with both preventive health care and social services. The
BHCHP continuum of care includes medical respite care,
allowing homeless persons to receive acute, subacute,
perioperative, recuperative and end-of-life care in a setting
that serves as an alternative to costly acute-care
hospitalizations.12 The BHCHP system of health care
delivery assures access to and provides quality medical
treatment for homeless individuals and families in the
Boston area.13

One of the case management

teams at the Boston Health Care
for the Homeless Program
(BHCHP) focuses on providing ongoing care to Bostons rough
sleepers. Through repeated
contact, an outreach team slowly
develops a relationship with Sam.
Eventually, Sam allows one of the
teams nurses to perform a basic
physical exam during which she
discovers an open and infected
wound. The nurse, with help from
the teams social worker,
convinces Sam to enter one of
BHCHPs respite care facilities to
receive intravenous antibiotic
treatment for his infection.
In this case, BHCHPs
comprehensive case management
provided a cost-effective
alternative to an emergency room
visit or hospital stay. Sam received
preventive care and early
treatment in a respectful and safe
environment.

Conclusion
Case management has become an established approach to quality health and mental
health care. This service component, when part of a health related program, should
always link directly to health conditions and employ support types and interventions
capable of improving the health status of those served. Case management services can
improve access to, coordination of and utilization of the health care system while also
producing a cost savings. These services are, at times, effective in creating a healthier
and more efficient system for serving the health care needs of individuals.

BIBLIOGRAPHY
Allness, Deborah J., and William H. Knoedler. The PACT Model of Community-Based
Treatment for Persons with Severe and Persistent Mental Illnesses. Arlington: Programs
of Assertive Community Treatment, Inc. 1998.
American Case Management Association. 1999-2003. 25 March 2003
http://www.acmaweb.org/.
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2002.
Brewer, Thomas. Program Associate. Archstone Foundation. Re: Case
Management. E-mail to Ryan Barker. 27 March 2003.
Brueckner, Nina. Executive Director. Community Health Clinic of Joplin. MFH Core
Grant Application #02-0268. Community Health Clinic of Joplin. 28 August 2002.
Butterfield Youth Services. 1997-2003. 25 March 2003 http://www.bys-kids.org/.
Boston Health Care for the Homeless. 2002-2003. IX Interactive. 7 April 2003
http://www.bhchp.org/.
Broderick, Francie, Joseph Yancey, Debbie Moorman, and Jim Nave. Community
Clients with Co-Occurrence of Mental Illness & Alcohol/Drug Abuse. Continuing
Education. St. Louis Psychiatric Rehabilitation Center. 12 March 2003.
Chen, Arnold, Randall Brown, Nancy Archibald, Sherry Aliotta, and Peter D. Fox. Best
Practices in Coordinated Care. Princeton: Mathematica Policy Research, Inc., 2000.
Case Management Resource Guide. 1999-2002. Dorland Healthcare Information. 4
April 2003 http://www.cmrg.com.
Case Management Society of Australia. 17 March 2003
http://www.cmsa.org.au/definition.html.
CMSA Case Management Society of America. 2003. 15 March 2003
http://www.cmsa.org.
Cress, Cathy. The Business of Case Management Flourishing in the United States.
Cresscare: Case Management Agency for Elders. 3 April 2003
http://www.cresscare.com/articles/flourish.html.
Frequent Users of Health Services Initiative. Review of Best Practices. Oakland:
Frequent Users of Health Services Initiative, 2002.
Grandinetti, Deborah. How Groups are Profiting from Case Management. Medical
Economics Magazine. 1998. 15 March 2003
http://www.findarticles.com/cf_dls/m3229/n15_v75/21101539/pl/article.jhtml.
Grech, Ethan. Case management: A Critical Analysis of the Literature. International
Journal of Psychosocial Rehabilitation 6 (2002): 89-98.
GVHP Provider Directory. 2001. Grand Valley Health Plan. 10 April 2003
http://www.gvhpchoosewell.com/providers/index.shtml.

10

Kanapaux, William. A Question of Standards. Behavioral Healthcare Tomorrow 9.1

(2000): 4, 14-16, 45.
Long, Michael. Cost Effectiveness of Case Management Programs for the Elderly.
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Long Beach Department of Health and Human Services. Senior Links to Independent
Living. Public Health Bulletin 2.2 (1999): 1-2.
Missouri Department of Social Services, Division of Medical Services. Missouri
Department of Mental Health, Division of Comprehensive Psychiatric Services. State
Advisory Council Policy and Standards Committee Meetings. January 2000 through
April 2000.
Morgenstern, Jon, Annette Riordan, Barbara S. McCrady, Katharine H. McVeigh,
Kimberly A. Blanchard, and Thomas W. Irwin. Research Notes: Intensive Case
Management Improves Welfare Clients Rates of Entry and Retention in Substance
Abuse Treatment. 2001. 27 March 2003 http://aspe.os.dhhs.gov/hsp/njsard00/retentionrn.htm.
Schore, Jennifer L., Randall S. Brown, and Valerie A. Cheh. Case Management for
High-Cost Medicare Beneficiaries. Health Care Financing Review 20.4 (1999): 87-101.
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and Prevention. Nation Center for HIV, STD and TB Prevention. Divisions of HIV/AIDS
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---. ---. Health Resources and Services Administration. Maternal and Child Health
Bureau. Office of Data and Information Management. Cost-Effectiveness of Case
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Government Printing Office, 2000.
---. ---. Office of Disability, Aging and Long-Term Care Policy. Rationing Case
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Westmoreland, Timothy M. To State Child Welfare and State Medicaid Directors. 19
January 2001. Targeted Case Management (SMDL #01-013). 23 April 2003
http://www.cms.gov/states/letters/smd119c1.asp.

11

ENDNOTES
1

Francie Broderick, Joseph Yancey, Debbie Moorman, and Jim Nave, Community Clients with
Co-Occurrence of Mental Illness & Alcohol/Drug Abuse, Continuing Education, St. Louis
Psychiatric Rehabilitation Center, 12 March 2003.
2

CMSA Case Management Society of America, 2003, 15 March 2003 http://www.cmsa.org/.

William Kanapaux, A Question of Standards, Behavioral Healthcare Tomorrow 9.1 (2000): 4,

14.

Deborah J. Allness and William H. Knoedler, The PACT Model of Community-Based Treatment
for Persons with Severe and Persistent Mental Illnesses (Arlington: Programs of Assertive
Community Treatment, Inc., 1998) 105-107.
4

CMSA http://www.cmsa.org/AboutUs/History.aspx.

CMSA http://www.cmsa.org/.

Deborah Grandinetti, How Groups are Profiting from Case Management, Medical Economics
Magazine, 1998, 15 March 2003
http://www.findarticles.com/cf_dls/m3229/n15_v75/21101539/pl/article.jhtml.
6

Michael Long, Cost Effectiveness of Case Management Programs for the Elderly,
Geriatric Times 2.3, 2001, 21 April 2003 http://www.geriatrictimes.com/g010531.html.
7

Jennifer L. Schore, Randall S. Brown, and Valerie A. Cheh, Case Management for High-Cost
Medicare Beneficiaries, Health Care Financing Review 20.4 (1999): 87-101.

Timothy M. Westmoreland, To State Child Welfare and State Medicaid Directors, 19 January
2001, Targeted Case Management (SMDL #01-013), 23 April 2003
http://www.cms.gov/states/letters/smd119c1.asp.
8

Nina Brueckner, Executive Director, Community Health Clinic of Joplin, MFH Core Grant
Application #02-0268, Community Health Clinic of Joplin, 28 August 2002.

Archstone Foundation, Annual Report 2001 (Long Beach: California State University, 2002) 10.

10

Archstone 10.

10

Long Beach Department of Health and Human Services, Senior Links to Independent Living,
Public Health Bulletin 2.2 (1999): 1-2.

11

Frequent Users of Health Services Initiative, Review of Best Practices (Oakland: Frequent
Users of Health Services Initiative, 2002) 22.
12

Frequent Users 22.

13

Frequent Users 22-24.

13

Boston Health Care for the Homeless, 2002-2003, IX Interactive, 7 April 2003
http://www.bhchp.org/.

12