Introduction to Care/Case Management

Introduction to Care/Case Management

Intro to Case Management1/15/031

Introduction to Care/Case Management

Teresa J. Kelechi, PhD, RNCS

January 15, 2003


Following this class, the student will be able to:

  1. discuss the differences between care management and case management
  2. describe three roles of the case/care manager
  3. describe a process for developing a case/care management model


American Accreditation Healthcare Commission. (2002, April). Disease management standards. Retrieved April 17, 2002, from

Ball, R. S. (2000). Nurse case managers and the internet. Lippincott’s Case Management, 5(5), 174-183.

Carneal, G., & D-Andrea, G. (2001). Defining the parameters of case management in a managed care setting. Managed Care Quarterly, 9, 55-59.

Goode, C. J., & Piedalue, F. (1999). Evidence-based clinical practice. Journal of Nursing Administration, 29(6), 15-21.

Goode, C. J., et al (2000). Outcomes from use of an evidence-based practice guideline. Nursing Economics, 18(4), 202-207.

Lee, D. T. F., et al (1998). Case management: A review of the definitions and practices. Journal of Advanced Nursing, 27(5), 933-939.

McCulloch, D. K., Price, M. J., Hindmarsh, M, & Wagner, E. H. (2000). Improvement in diabetes care using an integrated population-based approach in a primary care setting. Disease Management, 3(2), 75-82.

Standard, R. P. (1999). The effects of training in a strengths model of case management on client outcomes in a community mental health center. Community Mental Health Journal, 35(2), 169-179.

Glossary of terms:


•Began in 1990’s with shifts in:

–Reimbursement – capitation, HMOs, PPOs

–Ethical/legal issues – “defensive” medicine

–Acute to community/home/long-term care

–Health disparities/diminished access to care

–Market competition (University Medical Associates, Lowcountry Medical Associates)

Paradigm shifts

•Primary health care


–“seamless” health care delivery

–Wellness and prevention foci

–Non-medical determinants

•Socioeconomic status

Shifts continued

–Family violence

–Public health


–Financial models – incentives for aggregates

•Population-based capitation
•Contractual arrangements for group services

Challenges for case management

•Development of population-based health management

–Provide services for individuals, communities, special populations, institutions, health plans

–Address health status, quality of life, effectiveness of health care utilization


•Defining the consumer

–The ones who purchase health care

–The ones who pay for health care

–The ones who provide health care

•Who are the “partners” in care?

•What is the “health care delivery system”?


•From managing costs to managing care

–“2020” Vision: Health in the 21st Century”

–“Health People 2010 Program”

•From managing individuals to managing populations

•From nursing to interdisciplinary integration and coordination

What is nursing case management?

•Since 1985 (DRG’s)

–Professional practice model

–Focus on quality, outcomes-focused care while containing costs

•Appropriate length of stay
•Appropriate use of resources based on specific case types
•Integration and coordination of clinical services

What is case management?

–Monitors the use of patient care resources

–Supports collaborative practice and continuity of care

–Enhances patient and provider satisfaction

•Model varied


–Characteristics dependent on the discipline that employs its

–Personnel and staff mix (APN’s vs. RN’s)

What is nursing case management?


•Focuses on the coordination, integration, and direct delivery of patient services

•Places internal controls on the resources used for care

•Requires methods for monitoring patient care activity and resource distribution


•Critical paths (a description of patient care requirements in outline form)

•Case management plans (similar to the standard nursing care plan but adapted to nursing case management outcome standards)

•Multidisciplinary action plans (MAPs)

Approaches or model

–Within the walls (WWW) – acute care

–Beyond the walls (BTW) – outpatient/community-based, HMO

–Population-based disease management

–Environment-based population management

•Dialysis clinics
•School health clinics

Current Issues

•Need for documentation on measureable outcomes of nursing case management interventions

•Data reporting processes

•Systematic tracking (readmissions)

•Standardized language and documentation systems


•Education and competencies

•Compliance, regulation, and reimbursement issues

•Ethical considerations

Types of case management


–Specific groups

•Frail elderly
•Chronically ill who are functionally or emotionally challenged
•Long-term care clients

Social case management

•Emphasis on long-term care community

•Purpose to delay hospitalization

•Addresses health a social needs

•Focuses on independence through family and community

•Based on multidisciplinary approach

•Services might include homemaking, meals

Primary Care Case Management

•Role of gatekeeper based on medical model

•Based on treatment of health problem


•Regulates resource use to assure cost-effectiveness


•Services needs varied; depends on health problems

Medical-Social Case Management

•Focuses on long-term care population at risk for hospitalization

•Combines available resource utilization with added services not traditionally covered by health insurance

–Transitional care

•Various models

Medical-Social Models

•Generalist – acts as broker – does intake, coordination, and evaluation

•Primary case manager (CM) – therapeutic relationship – psych CNS

•Interdisciplinary team – functions divided among team members with specific expertise and specialization

Medical-Social Models

•Private case management – outside publicly-funded arena

•Services include coordination of services, social, functional and financial; mental health assessment and counseling; referral, monitoring and evaluation

•For elderly, home health care, homemaker and personal care services; family and legal counseling; physical therapy

Private case managers

•More individualized services

•Accessible on off hours, weekends, and holidays

•Rates based on hourly or set rates for out-of-pocket services, private insurance

Components of case management

•Client identification and outreach

•Individual assessment and diagnosis

•Service planning and resource identification

•Linking clients to needed services

•Service implementation and coordination

•Monitoring service delivery