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Case management

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Case management is an area of practice within several healthcare professions. Most case managers are nurses or social workers.

Case Management in Health Care[]

The Case Management Society of America defines case management as:

"a collaborative process of assessment, care planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes."[1]

Most nurse case managers work in hospitals or at health maintenance organizations.

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

1) Screening to find appropriate patients
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[2]

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.[3]

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. [2]

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 are 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.[3]

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. [2]

See also[]

References & Bibliography[]

  1. ↑ Case Management Society of America. Definition of Case Management. URL accessed on 2007-01-13.
  2. ↑ 2.0 2.1 2.2 William F. Bluhm, "Group Insurance: Fourth Edition," Actex Publications, Inc., 2003 ISBN 1-56698-448-3
  3. ↑ 3.0 3.1 Peter R. Koongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001 ISBN 0-8342-1726-0

Key texts[]

Books[]

  • Harris,M. & Bergman,H. C. (Eds.), Case management for mentally ill patients: Theory and

practice.Chronic mental illness, Vol 1. Langhorne, PA, US: Harwood Academic Publishers/Gordon & Breach Science Publishers.

Papers[]

  • Aberg-Wistedt, A., Cressell, T., Lidberg, Y., Liljenberg, B., Osby, U. (1995). Two-year outcome

of team-based intensive case management for patients with schizophrenia, Psychiatric Services, 46, 1263-6.

  • Bigelow, D.A., Young, D.J. (1991). Effectiveness of a case management program. Community Mental Health Journal, 27, 115-23.
  • Bond, G.R., Miller, L.D., Krumwied, R.D., & Ward, R.S. (1988). Assertive case management in

three CMHCs: a controlled study. Hospital and Community Psychiatry, 39, 411-418.

  • Burns, R., Creed, F., Fahy, T., Thompson, S., Tyrer, P., White, I. (1999). Intensive versus

standard case management for severe psychotic illness: a randomised trial. The Lancet, 353, 2185-89.

  • Byford, S., Fiander, M., Barber, J.A., Thompson, S.G., Burns, T., Van Horn, E. et al. (2000).

Cost-effectiveness of intensive v. standard case management for severe psychotic illness. UK700 case management trial. British Journal of Psychiatry, 176(JUN.), 537-543.

  • Chan, S., Mackenzie, A., & Jacobs, P. (2000). Cost-effectiveness analysis of case management

versus a routine community care organization for patients with chronic schizophrenia. Archives of Psychiatric Nursing, 14(2), 98-104.

  • Clark, R.E., Drake, R.E., Teague, G.B. (1993). The costs and benefits of case management. In M.

Harris,H. C. Bergman, (Eds.), Case management for mentally ill patients: Theory and practice.Chronic mental illness, Vol 1. (pp. 217-235). Langhorne, PA, US: Harwood Academic Publishers/Gordon & Breach Science Publishers.

  • Curtis, J.L., Millman, E.J., Struening, E., D'Ercole, A. (1992). Effect of case management on

rehospitalisation and utilisation of ambulatory care services. Hospital and Community Psychiatry, 43, 895-9.

  • Curtis, J.L., Millman, E.J., Struening, E., D'Ercole, A. (1996). Deaths among former psychiatric

inpatients in an outreach case management program. Psychiatric Services, 47, 398-402.

  • De-Cangas, J.P.C. (1995). Psychiatric nursing assertive case management: a comprehensive

evaluation of the effectiveness and outcomes of hospital based treatment versus a nurse directed assertive case management program. [[International Journal of Psychiatric Nursing Research]], 1, 72-81.

  • D'Ercole, A., Struening, E., Curtis, J.L., Millman, E.J., Morriss, A. (1997). Effects of diagnosis,

demographic characteristics, and case management on rehospitalisation. Psychiatric Services, 48, 682-88.

  • Ellison, M. L., Rogers, E. S., Sciarappa, K., Cohen, M., & Forbess, R. (1995). Characteristics of

mental health case management: results of a national survey. Journal of Mental Health Administration, 22, 101-12.

  • Ford, R., Beadsmoore, A., Ryan, P., Repper, J., Craig, T., Muijen, M. (1995). Providing the

safety net: Case management for people with a serious mental illness. Journal of Mental Health, 4, 91-7.

  • Ford, R., Rafferty, J., Ryan, P., et al. (1997), Intensive case management for people with serious

mental illness-site 2:cost-effectiveness. Journal of Mental Health, 6, 191-199.

  • Ford, R., Ryan, P., Beadsmoore, A., Craig, T., Muijen, M. (1997). Intensive case management

for people with serious mental illness- site 2: clinical and social outcome. Journal of Mental Health, 6, 181-90.

  • Franklin, J., Solovitz, B., Mason, M., et al. (1987). An evaluation of case management. American

Journal of Public Health, 77, 674-678.

  • Goering, P.N., Wasylenki, D.A., Farkas, M., Lancee, W.J., Ballantyne, R. (1988). What

difference does case management make? Hospital and Community Psychiatry, 39, 272-6.

  • Hassiotis, A., Ukoumunne, O.C., Byford, S., Tyrer, P., Harvey, K., Piachaud, J. et al. (2001).

Intellectual functioning and outcome of patients with severe psychotic illness randomised to intensive case management. Report from the UK700 trial. British Journal of Psychiatry, 178, 166- 171.

  • Holloway, F., Carson, J. (1998). Intensive case management for the severely mentally ill.

Controlled trial. British Journal of Psychiatry, 172, 19-22.

  • Hu, T.W., & Jerrell, J.M. (1998). Estimating the cost impact of three case management

programmes for treating people with severe mental illness. British Journal of Psychiatry, (Supp.l 36), 26-32.

  • Issakidis, C., Sanderson, K., Teesson, M., et al. (1999). Intensive case management in

Australia: a randomised controlled trial. Acta Psychiatrica Scandinavica, 99, 360-367.

  • Jerrel, J.M., Hu, T.W. (1989). Cost-effectiveness of intensive clinical and case management

compared with an existing system of care. Inquiry, 26, 224-234.

  • Johnston, S., Salkeld, G., Sanderson, K., Issakidis, C., Teesson, M., Buhrich, N. (1998).

Intensive case management: a cost effectiveness analysis. [[Australian and New Zealand Journal of Psychiatry]], 32, 551-559.

  • Knight, R.G., Carter, P.M. (1990). Reduction of psychiatric inpatient stay for older adults by

intensive case management. [[[The Gerontologist]], 30, 510-5.

  • Macias, C., Kinney, R., Farley, O.W., Jackson, R., Vos, B. (1994). The role of case management

within a community support system: partnership with psychosocial rehabilitation. [[Community Mental Health Journal]], 30, 323-39

  • Marshall, M., Gray, A., Lockwood, A., & Green, R. (2002) Case management for people with

severe mental disorders (Cochrane Review). In The Cochrane Library, Issue 3, Oxford: Update Software. McFarlane, W.R., Stastny, P., & Deakins, S. (1992). Family-aided assertive communitytreatment: a comprehensive rehabilitation and intensive case management approach for persons with schizophrenic disorders. New Directions for Mental Health Services, 53, 43-54.

  • McGurrin, M.C., Worley, N. (1993). Evaluation of intensive case management for seriously

and persistently mentally ill persons. Journal of Case Management, 2, 59-65.

  • Modcrin, M., Rapp, C., Poertner, J. (1988). The evaluation of case management services with the chronically mentally ill. Evaluation and Program Planning, 11, 307-14.
  • Morse, G.A., Calsyn, R.J., Klinkenberg, W.D., Trusty, M.L., Gerber, F., Smith, R., et al. (1997).

An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatric Services, 48, 497-503.

  • Nelson, G.S. (1995). Changes in rates of hospitalization and costs savings for psychiatric

consumers participating in a case management program. Psychosocial Rehabilitation Journal, 18(3), 113-123.

  • Okpaku, S.O., Anderson, K.H., Sibulkin, A.E., Butler, J.S., Bickman, L. (1997). The

effectiveness of a multidisciplinary case management intervention on the employment of SSDI applicants and beneficiaries. Psychiatric Rehabilitation Journal, 20, 34-41.

  • Preston, N.J., & Fazio, S. (2000). Establishing the efficacy and cost effectiveness of community

intensive case management of long-term mentally ill: a matched control group study.Australian & New Zealand Journal of Psychiatry, 34(1), 114-121.

  • Rossler, W., Loffler, B., Fatkenheuer, A., & Riecher-Rossler, A. (1995). Case management for

schizophrenic patients at risk of rehospitalization -a case control study. [[European Archives of Psychiatry and Clinical Neuroscience]], 246, (1) 29-36.

  • Rossler, W., Loffler, W., Fatkenheuer, B., & Reicher-Rossler, A. (1992). Does case management reduce rehospitalisation rates? Acta Psychiatrica Scandinavica, 86, 445-9
  • Sands, R. G., & Cnaan, R. A. Two modes of case management: assessing their impact.Community Mental Health Journal, 30, (5) 441-457.
  • Schmidt-Posner, J., Jerrel,l J. M. (1998). Qualitative analysis of three case management

programs. Community Mental Health Journal, 34, (4) 381-392.

  • Scott, J. E. D. (1995). Assertive community treatment and case management for schizophrenia.

Schizophrenia Bulletin, 21, (4) 657-668.

  • Solomin, P., & Draine J. (1994). Family perceptions of consumers as case managers.Community Mental Health Journal, 30, 165-76.
  • Solomon, P., & Draine, J. (1994). Satisfaction with mental health treatment in a randomized

trial of consumer case management. Journal of Nervous and Mental Disease, 182, 179-84.

  • Solomon, P., Draine, J. (1995). Consumer case management and attitudes concerning family

relations among persons with mental illness. Psychiatric Quarterly, 66, 249-61.

  • Surles, R. C., Blanch, A. K., Shern ,D. L., & Donahue, S. A. (1992). Case management as a

strategy for systems change. Health Affairs, 11, 51-163.

  • Wolff, N., Helminiak, T. W., Morse, G. A., Calsyn, R. J., Klinkenberg, W. D., & Trusty, M. L.

(1997). Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients. American Journal of Psychiatry, 154, (3) :341-348.


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