Case management (US health system)

Case management is a managed care technique within the health care coverage system of the
United States. It involves an integrated system that manages the delivery of comprehensive
healthcare services for enrolled patients.[1] Case managers are employed in almost every aspect of
health care and these employ different approaches in the control of clinical actions.[1]

Contents
In health care
Functions
Health insurer and HMO setting
Health care provider setting
Employer setting
Case management models
Nursing Case Management Certification
Health Care Delivery System Case Management
See also
References
External links

In health care
The American Case Management Association (ACMA), a non-profit association dedicated to the
support and development of the profession of case management through educational forums,
networking opportunities, legislative advocacy and establishing the industry's Standards of
Practice,[2] defines case management as:

"a collaborative process of assessment, planning, facilitation, care coordination, evaluation,

and advocacy for options and services to meet an individual's and family's comprehensive
health needs through communication and available resources to promote quality
costeffective outcomes."[3]

Case management is multifaceted as the following definition highlights:

"Case management is a procedure to plan, seek, and monitor services for different social agencies
and staff on behalf of a client. Usually one agency takes primary responsibility for the client and
assigns a case manager, who coordinates services, advocates for the client, and sometimes
controls resources and purchases services for the client. The procedure allows many social
workers in the agency, or in different agencies to coordinate their efforts to serve a given client
through professional teamwork, thus expanding the range of needed services offered."
The Certified Case Manager (CCM) credential is available to health care providers licensed to
practice independently in the American health care system. For example, the license would be
available to Registered Nurses but not Licensed Practical Nurses, who are not licensed to assess
and evaluate the health of their clients.

Because holistic training is the basis for the Registered Nurse, Social Work, Occupational therapy
and most all degree programs in the health sciences, the transition into case management is a
natural progression of skill. To investigate if your specialty is among those able to earn this
specialty certification, go to
https://web.archive.org/web/20100325003803/http://www.ccmcertification.org/secondary.php?
section=Certification&content=ApplyForCertification, and read the requirements for application
for this certification.

Case management focuses on delivering personalized services to patients to improve their care,
and involves four steps:

1) Referral of new patients (perhaps from another service if the client has relocated to a
new area out of previous jurisdiction, or if client no longer meets the target of previous
service, such as requiring a greater level of care. Alternatively, they may be referred after
having been placed on an ITO or in an inpatient unit.
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 program[4]

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.[5]

Specific types of case management programs include catastrophic or large claim management
programs, maternity case management programs, and transitional care management
programs.[4]

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.[4]
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 who are at 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.[5]

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.[4]

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.[4]
6) Assist employees to seek specialized treatment when need arises.

Case management models

There are several models of case management and the distinctions are based on internal and
external influences that have bearing on the level of success and differences in outcomes. These,
for instance, include local influences such as the response to cost by funders of care and
consumer pressure.[1] The generic model used in the United States is the chronic care model,
which holds that health care does not only involve change in the patient and that high-quality
disease care counts the community, the health system, self-management support, delivery system
design, decision support, and clinical information systems as important elements in the practice
of case management.[6] There is also the group decision-making models such as the rational
model, which focuses on economic perspectives and maximum utility; and, the garbage can
model, an approach based on difficult problem identification and solutions under uncertain
circumstances.[7] Other models also prioritize ethics such as the distributive justice model
developed by Beauchamp and Childress of the Kennedy Institute of Ethics, where ethics a
component of the case manager's responsibilities and is concerned with the distribution of finite
resources for the benefit of an entire community.[8]

Nursing Case Management Certification

The American Nurses Credentialing Center (ANCC) is the largest board certification body for
nurses in the United States.[9] One of the many certifications that ANCC offers is a Case
Management Nurse Certification. Registered nurses who successfully pass ANCC's Case
Management Nurse exam[10] are entitled to use the credential, RN-BC (Registered Nurse - Board
Certified).

Health Care Delivery System Case Management

The American Case Management Association (ACMA) (http://www.acmaweb.org), 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.[11]
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 (http://www.acmaweb.org/section.asp?sID=16), 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 consists 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 4,500 members, and is represented by 21 state chapters nationwide. ACMA
provides hospital-focused education and networking for Case Managers – including nurses,
social workers, physicians, administrators and other health care professionals.

See also
◾ Case management (mental health)
◾ Managed care
◾ Medical case management
◾ Nursing process
◾ Utilization management

References
1. Snoddon, Janet (2010). Case Management of Long-term Conditions: Principles and Practice
for Nurses. Malden, MA: John Wiley & Sons Ltd. pp. 19–21. ISBN 9781405180054.
2. American Case Management Association. "Standards of Practice for Case Management" (htt
p://www.acmaweb.org/SOP). Retrieved 2011-09-30.
3. American Case Management Association. "Definition of Case Management" (http://www.acm
aweb.org/). Retrieved 2011-09-30.
4. William F. Bluhm, "Group Insurance: Fourth Edition," Actex Publications, Inc., 2003 ISBN 1-
56698-448-3
5. Peter R. Koongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen
Publishers, Inc., 2001 ISBN 0-8342-1726-0
6. Mullahy, Catherine (2010). The Case Manager's Handbook. Sudbury, MA: Jones & Bartlett
Publishers. p. 795. ISBN 9780763777241.
7. Nagelkerk, Jean (2005). Leadership and Nursing Care Management. New York: Elsevier
Health Sciences. p. 48. ISBN 9781416031611.
8. Daniels, Stefani; Ramey, Marianne (2004). The Leader's Guide to Hospital Case
Management. Sudbury, MA: Jones & Bartlett Learning. p. 277. ISBN 9780763733544.
9. "Archived copy" (https://web.archive.org/web/20080705025813/http://www.nursecredentialin
g.org/Certification.aspx). Archived from the original (http://www.nursecredentialing.org/Certific
ation.aspx) on 2008-07-05. Retrieved 2008-11-17.
10. "Archived copy" (https://web.archive.org/web/20081201012604/http://www.nursecredentialin
g.org/NurseSpecialties/CaseManagement.aspx). Archived from the original (http://www.nurse
credentialing.org/NurseSpecialties/CaseManagement.aspx) on 2008-12-01. Retrieved
2008-11-17.
11. Confluence Writing Award--Aaron Sommers' Case Managing.

External links
◾ Commission for Case Manager Certification (http://www.ccmcertification.org)
◾ American Case Management Association (http://www.acmaweb.org)

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