Case Management

As health care has become more complex, the need for an organized approach to providing care has become mandatory. Individuals with chronic health disorders must often access a variety of health services, diagnostic procedures, and therapies that require coordination to ensure that appropriate services are provided at appropriate times. This need for coordination becomes even more important in the current era of health care, because services that are traditionally defined as “health care,” that is, are provided by a physician or in the hospital, now interface with numerous social services, such as counseling, exercise programs, and transportation services. The goal of case management involves creating a support structure to ensure that patients receive appropriate services at the appropriate time with an expected outcome.

As defined by the Case Management Society of America, “Case management is 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” (http://www.casemanagement.com/, July 2002). Case management is an integral part of care management, an approach to health care that takes into account the various stages of a disease process or clinical condition and musters the health care system to provide appropriate resources throughout the continuum of the condition. Case management usually is applied to the most seriously ill people first, because those are the most likely to need health care services and coordination of care to ensure the best outcomes. For these types of patients, a case manager performs a number of functions:

• Thoroughly understanding the patient, the diagnosis, stage of illness, and the environment in which the patient lives, including local medical and social services, as well as family resources
• Gathering appropriate background and resource information regarding the best methods of treating the patient's illness at each stage
• Understanding the treatment regimen prescribed by attending and consulting physicians in the context of availability of resources in the patient's environment
• Working with the patient, family members, and health care providers to formulate an acceptable and appropriate plan for the patient's care
• Implementing processes to assure that the patient receives the required care, performs the necessary monitoring procedures, and undergoes diagnostic testing and therapeutic procedures at the scheduled times
• Monitor care and communicate with providers, family members, and the patient in an effective and timely manner
• Monitor the financial and insurance issues in the patient's care to ensure adequate financial resources for services and procedures

[Page 65]The attention to detail required for this process generally requires a health care professional dedicated to managing the process of care, and in most cases, nursing professionals serve as case managers. Depending on the clinical condition, the nursing professional can be a registered nurse, but sometimes an advanced practice nurse's expertise is required. The case manager must have a good grasp of the clinical condition or disease entity, as well as of the many variations that may occur in the clinical course. Case managers become intimately familiar with health conditions in ways that are unique to their position in the health care management team.

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