Case Management Models

Case Management Domains  The case manager's sphere of influence and activity are:  Processes and Relationships  Health Care Management  Community Resources and Support  Psychosocial Intervention  Rehabilitation Case Managemen.

Target Patient Populations A.Diagnostic category (DRG) 1.Acute injury or illness 2. Chronic illness 3.Complex treatment plan B.Potential for large consumption of resources 1. Financial 2.Community C.Frail and elderly D.Hospitalized E.Procedure (e.g., chest physiotherapy [CPT])

Acute Inpatient Care Models  Acute care models are the most often cited models in case management literature.  The focus of the case management services in the acute care setting is on one episode of care from admission to discharge.  In many instances, it encompasses utilization management or discharge planning functions.  Typically, registered nurses or social workers provide the case management services

Community-Based Models  Community-based models can provide case management services throughout the continuum of care or at a specific practice setting.  Additionally, it can be in either a provider or payer setting.

Primary Care Case Management  The focus is on the role of gatekeeper, focusing on the treatment of health problems, maintaining the individual in the lowest level of care possible.  The case manager is either a physician or an advanced practice nurse.

Geriatric Care Management 1.Medical-Social Case Management  Team approach focusing on the long-term- care population. Coordinates services that are usually not covered by insurance plans to prevent institutionalization. 2.Private Geriatric Case Management  Provides social and health access and coordination to the elderly, with an emphasis on long-term-care issues, maintaining them in the lowest level of care.

Long-Term or Chronic Care Case Management Model  Much like geriatric case management, long- term or chronic care case management provides for social and health needs but serves other populations with long-term care and chronic care needs.

Independent Case Management Models  There is no provision of direct patient care. The focus is on enabling the patient to make the needed transitions through the health care delivery system, monitoring resource utilization, managing costs, and providing quality services.

Integrated Delivery System Model- Systems Model  The case manager is assigned to the case at one of defined access points, depending on where services were provided.  The responsibility for case management resides at the location where the patient is receiving care, and continuity is maintained by providing referral and tracking services.

Managed Care Model  The main objective of the model is to contain costs by controlling utilization and coordinating care. Two types of case managers are described: 1.Financial case manager-functions in a traditional utilization management model, and the role is high volume/low intensity 2.Clinical case manager-the focus is on high- intensity Low-volume interventions with high-risk patient populations