Case Management
%20In%20Nursing.png "Case Management (CM) In Nursing")
Case Management
Case management (CM) is a growing patient care delivery structure that has been implemented in almost all care settings including acute, subacute, ambulatory (emergency departments and outpatient clinics), long-term, insurance health organizations, community-based centers, and palliative /hospice.
Despite the fact that CM has been recognized as an effective and desirable approach to care delivery for the patient and the health care organization, there continues to be little consensus as to what CM is, which resulted in the absence of a standard or universal definition.
The literature contains multiple definitions
for CM, and each definition frequently de pends on the setting and model that
is used, the discipline that employs it, and the type of personnel used to
accomplish the functions (Cohen & Cesta, 1997); that is, those who assume
the role of the case manager.
Literature Review And Case Management
There is no clear agreement in the literature about the definition and component activities/elements of CM practice. There also exists considerable confusion regarding what constitutes CM, who is best to assume the case manager's role, and which owns professional discipline or should own the account ability for the practice of CM.
Some healthcare professionals view CM as a patient care delivery system; others see it as a process or an approach to better care delivery and outcomes. This difference in perception results in differences in the scope of CM practice.
For example, when CM is viewed as a delivery system,
its scope is wide and entails a continuum of care focus that transcends beyond
one care setting or an episode of illness. However, as an approach to care or a
process, it tends to be narrow, short-term, and focuses on one episode of
illness/care, addresses the main issue(s) at that point in time, and takes
place in a specific one care setting.
Multiple Case Management Model
There are multiple case management models in use today; however, all share similar aims: to improve health care delivery (access, continuity, and quality), eliminate fragmentation and duplication of services, and control or reduce costs.
Models include private or independent case management, social case management, primary care case management, nursing case management, advanced practice case management, telephonic case management, disability case management (including rehabilitation and vocational counseling), chronic care, worker's compensation, and insurance case management (Cesta & Tahan, 2003).
Regardless of the model, core functions identified are integration of care
across the continuum, consumer advocacy, coordination of services among
providers, and direct delivery of services to meet patient needs efficiently
and effectively attending to cost and the use of resources (Cohen & Cesta,
1997; Cesta & Tahan).
When
attempting to define CM, one must examine the views of two professionally
credible and leading groups in the delineation of the knowledge base for CM.
These are the American Nurses Association (ANA) and the Case Management Society
of America (CMSA). The ANA defines CM as:
A dynamic and systematic collaborative approach to providing and coordinating health care services to a defined population. It is a participative process to identify and facilitate options and services for meeting individuals' health needs, while decreasing fragmentation and duplication of care and enhancing quality, cost-effective outcomes ---(American Nurse Credentialing Center JANCCI, 1999, p. 3)
The CMSA Defines CM As
A
collaborative process which assesses, plans, implements, coordinates, monitors,
and evaluates options and services to meet an individual's health needs through
communication and available resources to promote quality cost-effective
outcomes (CMSA, 2002).
Specific Use of Case Management
Case management as a concept and role function is not new. It has been used by mental health providers, public health nurses, and social services for about a century.
The use of CM in the US goes back to the last quarter of the 19th century in the provision of care for the immigrants by the settlement houses (in 1860), and in coordinating public human services by the first Board of Charities in Massachusetts (in 1863) (Tahan, 1998).
Around the turn of the 20th century, the use of CM became popular in the public health sector and in community-based social work services in the form ofz After World War II and in the 1950s, CM branched into the area of mental health specially to keep veterans out of the hospital (Tahan).
Major emphasis in the past was on the recipient of care and the coordination of services to meet the needs of the patient or client. However, more recently (especially since the mid-1980s), case management has become a dominant and desired approach to care and cost savings in the context of market-driven health care reform.
The federal government enhanced the use of case management during the 1970s by way of funding certain community-based demonstration projects. However, the nurse case management model was first introduced in 1985 as a relatively new out- growth of primary nursing and as a strategy to counteract the nursing shortage and meet the demands of the prospective payment system.
This case management model emphasized early assessment and intervention, comprehensive care planning, and service system referrals to specialty providers (Cohen & Cesta, 1997). In the early 1990s and due to the proliferation of managed care, nursing case management models increasingly became interdisciplinary in structure.
Hence, the case management model of today focuses on
inter professional collaboration, with the case manager assuming the role of the
gatekeeper of health care delivery and services.
Case Management and Managed care
Case management and managed care are two dominant concepts in discussion today in relation to the challenges of managing patients and resources in a cost-conscious and quality health care delivery system.
Although managed care and case management are used to achieve effective management of care, it is important to differentiate between these two terms. Managed care can be described as a general system of care delivery that has re- placed fee-for-service systems of care for improved management of resources, costs, quality, and effectiveness of health services.
Case management, on the other hand, is a process of care that may be used as one strategy to control costs and inappropriate use of resources and services in a managed care system.
Nursing
case management provides out-comes-oriented care with attention to appropriate
hospital length of stay and access to services, monitors use of patient care
services based on type of client, integrates and coordinates clinical services,
fosters continuity of care in the context of interdisciplinary and
collaborative practice, and enhances patient and provider satisfaction (Cohen
& Cesta , 1997; Cesta & Tahan, 2003).
CM Practices In Literature
The literature describing CM practice and its outcomes is focused on select areas associated with the design, structure, roles, processes, implementation, and evaluation of these CM models; however, the absence of theoretical underpinnings for these descriptions is dominant.
Nurse scholars have pursued the conduct of CM evaluative research to validate its value, aims, and outcomes, L., cost-effectiveness and quality care.
Although it is evident in the literature that research supports these goals and strengthens the benefits of implementing CM strategies for the provision of care, the ability to link these outcomes to the CM system has not been as strong because of the lack of clear or standardized definitions for either CM or CM interventions or outcome measures/indicators.
In addition, there seems to be a lack of clear theoretical
frameworks that define the relationships between the structure and processes of
CM interventions and their effect on outcomes, or that integrate the different
aspects of CM practice (Tahan, 2003).
CM Model Evaluation
The CM research literature shows that CM models are rarely appropriately evaluated, and in some instances the variables examined are loosely defined or measured. In most of the studies the research design, data collection, and sampling methods seem to be an "afterthought."
The dominant approach to CM evaluation is the examination of cost and quality outcomes employing performance improvement and outcomes-measurement study designs. The dominant research studies are basically retrospective attempts at validating the value of CM.
Although in some cases structure, process, and outcome variables are examined, evaluating the interrelationships among the variables or how they affect each other remains lacking.
The majority of the published studies are primarily descriptive in nature and tend to ignore examining the effects of confounding variables (eg, denials and appeals management, interdependence among multiple professionals including the physicians) that may have influenced the results obtained.
Therefore, the significance and utility of these studies are compromised (Tahan, 2003). Issues of cost, quality, access to care, and scope of services should be examined when evaluating CM delivery models, especially be- cause of the claim that they are implemented to improve access to care, enhance quality, and control costs.
The examination of these variables is essential so that the implications of CM for health policy decisions can be heightened. Very rarely a combination of these four variables is examined.
The combination of variables most commonly used is cost and quality or access and quality. This existing limitation may be attributed to the challenge of conducting a study that combines the four types of variables.
Such studies are also known to be complex, costly, time consuming, and require the coordination of a professional with specialized knowledge base in CM practice and research methods.
Other challenges are attributed to the confusion of identifying the classification of the variables studied, such as readmission rate, complication rate, and length of stay, which are defined as both cost and quality variables depending on the researcher conducting the evaluation.
Such confusion results
from the lack of theoretical underpinnings of CM practice, con model
frameworks, or standard definitions of the variables examined (Tahan, 2003).
Structure and Outcomes of CM
Designing a study that evaluates the inter connectedness and relationships of structure, process(es), and outcomes of CM models is not an easy task. Research related to CM can be approached by evaluation research, experimental or quasi-experimental designs, or qualitative methods.
However, because of the challenge of marching, randomizing, or controlling for control and experimental groups, quasi -experimental research is frequently used. CM research may focus on the processes of care (describing and differentiating CM models of care delivery) or on the outcomes of care that frequently include outcomes indicators such as quality and cost measures.
Examples may include decreased length of stay, reduced hospitalization or rehospitalization rates, nonroutine visits to providers and emergency departments, and consumer satisfaction.
However,
outcome studies must not dominate the research without attention to the
specific structure (context of care delivery) and processes (tasks, activities,
and behaviors) of care that may influence evaluation studies of CM practice.
Data Collection Methods For CM
Data collection may be facilitated through the use of patient questionnaires, self-report instruments completed by those providing CM services, or large data sets from health care provider agencies or payers.
Issues And Problems In CM
Issues and considerations related to CM roles and functions must be addressed.
Two of the most significant issues related to the implementation of CM roles and research related to CM are educational preparation and ethical competence of the case manager, because this practice arena continues to be changing rapidly, it has been difficult for educators to clearly define core competencies of the case manager and to be clear about the necessary level of educational preparation.
Also, the various models of CM require attention to the structure of care, for
whom the case manager works, and the primary purpose of the CM role. These
issues impact the research designs and questions, depending on setting, type of
case manager, and population managed by case managers.
Another critical issue related to CM that affects practice and research is that of ethics. Because many case managers face compering loyalties and priorities, the question of ensuring ethical competence becomes as important as clinical, intellectual, financial, and administrative competence.
Cohen and Cesta (1997) identified six challenges to be dressed in practice and research as the role of case manager continues to evolve:
(a) fidelity to the unique needs of individual patients
(b) competing loyalties
(c) resolving role conflicts
(d) owning responsibilities to underserved populations
(e) identifying personal biases
(f) balancing care for others with appropriate self-care
Additional important ethical issues are consumer advocacy, balancing access to
care and services with cost-effectiveness, and ensuring that consumers' rights
and safety are protected.
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