Overview of Case Management Susan Chapman, PhD, RN N 226 Guest Lecturer February 12, 2003

2/12/032 What is Case Management? A process that enhances continuity and appropriateness of care and setting Coordination across care settings Involves cross-disciplinary decision making Involves family members/support network Requires specialized knowledge

2/12/033 History of Case Management Public health nursing-transition to home 1970s - origins in Workers Comp and mental health managed care, high cost cases assist in navigating health care system Disease management - focus on single disease/condition J. Ebert. Public Health Nursing,. Vol 18(5) 2001

2/12/034 What are the Goals of Case Management? Coordinate complex illnesses/conditions Control costs/resources Decrease length of stay Avoid hospitalization Increase patient/family satisfaction Improve outcomes Provide comfort measures Overall to improve quality of care

2/12/035 Why Nurses for Case Managers? Nursing process is involved Critical thinking/decision making Clinical skills Teaching skills Communication skills Ability to work with multiple disciplines Cost effective Knowledge of spectrum of health services

2/12/036 Critical Pathways/Clinical Guidelines Millman & Robertson, others Actuarially- based algorithms predicting/proscribing care pathway Care Maps - used in care settings Specific criteria, processes Local home grown or national Governments role in creating clinical guidelines

2/12/037 What is the Evidence? Criteria for success focused on cost savings Satisfaction measures indicate some patients and families are helped Some evidence of improved outcomes –decreased rate of hospitalization –decrease in physician visits –stable or improved clinical indicators Need more research on outcomes and quality

2/12/038 Stories from the Front Lines of Case Management Case management in a managed care company Focused on high cost/catastrophic cases Role evolved to coordination and navigating the system Provide link between various practitioners Allowed flexible interpretation of benefits Frequent contact/family support

2/12/039 Ethical Issues in Case Management Is case management a form of rationing? Is patient choice denied? Is population more important than the individual? Confidentiality issues Competing loyalties (employer, patient)

2/12/0310 Disease Management and Future Directions Focus on single diseases/systems, chronic illness –Diabetes –CHF –COPD Goal to avoid hospitalization Group treatment/visits/classes Kaiser Permanente is innovative in care management, e.g., COPD program

2/12/0311 For More Information Case Management Resource Guide cmrg.com Case Management Society of America cmsa.org Health Plan web sites Nursing organizations Resources for specific diseases/conditions