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
you’ve 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 patient’s 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:

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 • 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 1960’s resulted in increased community-based case management
services that now function as a key element of treatment.3 The 1990’s 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

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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.

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 Overview of Health Case Management, Diagram #2

Support Type Intervention

Service
Single Visit Enhancement:
Goal: Simple Supports Health
Intervention
Resolution

Targeted Case
Assessment Limited Contact Management:
Goal: Address Involves major
Individual Case sources of support Improved
Referral Manager most critical
Health
or problems
Team Case Status
Management Comprehensive
Defined Duration Case Management:
Goal: Establish Involves all known
sources of care
Equilibrium

On-Going Care
Hybrid Models
Goal: Maintain
Stability

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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 Meet the Smith Family
Community Health Clinic of Joplin in November of 2002. The Mrs. Smith brings her 10-
purpose of this grant was to hire two medical social workers to year-old son, Jack, to the
Community Health Clinic
provide case management services for patients. These case because of his stomach
managers initially verify the indigent status of those seeking cramps and diarrhea. An
initial screening by a case
services from the clinic. Eligible individuals then receive free manager determines the
family’s eligibility for services.
medical treatment from volunteer doctors, dentists and
pharmaceutical staff. After receiving care for their immediate A doctor’s exam results in the
diagnosis of round worms.
medical need, patients are sent back to the case managers While the prescribed
(Referral) who work to ensure that basic needs are being met medication will solve the
immediate problem, the
(Assessment). Many who attend this clinic are so doctor is concerned about
impoverished that basic lacks in food, clean water and medical reinfection because the
family does not have access
supplies lead to their illnesses, or significantly impede their to clean drinking water.
recovery. The social workers link individuals and families to
The Smith family is referred
community resources in order to improve their health status to one of the case managers
who meets with them and
and prevent further health complications. Often the needed connects them to a
interventions are accomplished through a single interaction community resource where
the family can receive free
with a case manager (Support Type). However, sometimes bottled water.
follow-up or on-going contact may be necessary to ensure a
This single encounter with
positive health outcome (Support Type). The services offered the case manager supports
the doctor’s health
by these case managers support and enhance the medical
intervention and supplies the
treatment provided by the clinic’s doctors (Intervention).8 family with a permanent
solution for their immediate
need.

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 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.
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.
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.
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 Betty’s health
needs.
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
and healthy environment.”9 A three-part approach including
community education, a telephone resource line and case
management services facilitates the achievement of this goal.
Community agencies such as the City’s 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
consisting of a public health nurse and a social worker
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
and a primary care provider. This short-term, targeted case
management (Intervention) stabilizes the immediate
situation and preserves the health and independence of the
senior.10
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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
hospital-based primary and specialty care with direct care homeless. He prefers not sleeping
in the shelters and prides himself
services at over 70 shelter and outreach sites in on his fierce independence. He
lives by the motto of “Trust No
metropolitan Boston.”11 Staff at these service organizations
One.”
refer homeless individuals into BHCHP (Referral). Once a
One of the case management
new client enters the program, a team of doctors, nurse teams at the Boston Health Care
practitioners, physician assistants, nurses and social for the Homeless Program
(BHCHP) focuses on providing on-
workers assesses the individual’s needs (Assessment) going care to Boston’s “rough
and provides on-going monitoring and care sleepers.” Through repeated
contact, an outreach team slowly
(Support Type). BHCHP uses comprehensive case develops a relationship with Sam.
management (Intervention): (1) to resolve critical health
Eventually, Sam allows one of the
issues through linkages to appropriate health care team’s nurses to perform a basic
physical exam during which she
providers and (2) to maintain stability through connections discovers an open and infected
with both preventive health care and social services. “The wound. The nurse, with help from
the team’s social worker,
BHCHP continuum of care includes medical respite care, convinces Sam to enter one of
allowing homeless persons to receive acute, subacute, BHCHP’s respite care facilities to
receive intravenous antibiotic
perioperative, recuperative and end-of-life care in a setting treatment for his infection.
that serves as an alternative to costly acute-care
In this case, BHCHP’s
hospitalizations.”12 The BHCHP system of health care comprehensive case management
provided a cost-effective
delivery assures access to and provides quality medical alternative to an emergency room
treatment for homeless individuals and families in the visit or hospital stay. Sam received
preventive care and early
Boston area.13 treatment in a respectful and safe
environment.

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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.

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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/.

Archstone Foundation. Annual Report 2001. Long Beach: California State University,
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.

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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.”
Geriatric Times 2.3 (2001). 21 April 2003 http://www.geriatrictimes.com/g010531.html.

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/retention-
rn.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.

United States. Department of Health and Human Services. Centers for Disease Control
and Prevention. Nation Center for HIV, STD and TB Prevention. Divisions of HIV/AIDS
Prevention. HIV Prevention Case Management – Literature Review and Current Practice.
September 1997. 19 March 2003 http://www.cdc.gov/HIV/pubs/pcml/pcml-doc.htm.

---. ---. Health Resources and Services Administration. Maternal and Child Health
Bureau. Office of Data and Information Management. Cost-Effectiveness of Case
Management and Home Visiting: A Review of the Literature. Washington, D.C.: U.S.
Government Printing Office, 2000.

---. ---. Office of Disability, Aging and Long-Term Care Policy. Rationing Case
Management: Six Case Studies. Washington D.C.: U.S. Government Printing Office,
1994.

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.

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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/.
3
William Kanapaux, “A Question of Standards,” Behavioral Healthcare Tomorrow 9.1 (2000): 4,
14.
3
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.
5
CMSA http://www.cmsa.org/.
6
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.
7
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.
9
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/.

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