Case management

Case management is a process in which the health and human services needs of a chronically or catastrophically ill patient are coordinated to ensure the best possible outcome for the patient and family, the health care providers, and the payers, such as health insurance companies. It involves determining what the patient needs to reach a maximum level of health and function, and how best to meet those needs with the available resources. The case manager, usually a nurse or other medical professional, will serve as a point of contact between all the partners in the situation, serving as an advocate and guide for the patient in navigating the health care system. This will usually include communicating with providers and payers; researching and arranging for assistance such as mobility aids, home medical equipment, and transportation; and coordinating care between multiple providers. Case management has become increasingly important as health care costs have continued to rise.

Background

Case management had its origins in the nineteenth century with the rise of organized nursing programs. Trained nurses realized the importance of hygiene, nutrition, adequate clothing, and shelter to maintaining health. They were also often aware of options for health care, such as clinics, where a sick or injured person could receive medical assistance. They began promoting these services to the sick people they tended and advocating for more such services.

In many cases, these efforts began with the most vulnerable, such as infants and children, disabled individuals, and the elderly. The nurses' goal was to provide the best possible outcome for the patient, whether that was a healthy childhood, an improved ability to get around, or a dignified and pain-free death. Florence Nightingale and the nurses trained through her schools were pioneers in this, as was Lillian Wald.

Wald, a nurse trained at the New York Hospital, became aware that many immigrants in Manhattan lacked access to medical care, including pre- and postnatal care when they had babies. In 1893, she founded the Visiting Nurse Service of New York, which in the early twenty-first century is the largest nonprofit home health care agency in America. This program helped spark interest in organizing and coordinating health care services for the poor and underserved populations, especially in large urban areas. These efforts led to the formation in the early 1900s of the US Public Health Service, which focused on the sanitation and immunization needs of a population that was increasingly concentrated because of the nation's industrialization.

By 1905, hospitals were beginning to hire social workers to help patients get care without duplicating services. In 1910, the first Blue Cross health plan was founded in Texas; this led to additional interest in case management, as health insurers attempted to get the best results possible for the money being spent. The federal government approved the Social Security Act in 1935; this was the first time the national government became involved in helping individuals have access to the health care they needed. Efforts to coordinate care for veterans returning from World War II in the 1940s also increased awareness about and efforts in case management.

The 1960s and 1970s saw increased efforts to provide and coordinate care for the disabled, including the passage of the Medicare and Medicaid programs, which became law in 1965. The importance of case management grew as government agencies and insurers tried to ensure patients were getting the best possible care for the money being allocated. These legislative efforts and others, including the Americans with Disabilities Act (1990), the Family and Medical Leave Act (1993), the Health Insurance Portability and Accountability Act (1996), and the Patient Protection and Affordable Care Act (2010), all increased the importance of case management as a way to make sure the patient got all the care needed to improve and maintain the optimal level of health.

Overview

The earliest professional nurses realized quickly that neither the mother nor the infant was going to do well if the mother did not understand the need to maintain a clean environment, or lacked sufficient food so she could eat well enough to nurse her child. Patients with injuries or chronic illnesses faced similar issues; lack of sanitation could cause infections that complicated care, while nourishing food was necessary for recovery and ongoing health. Some patients faced other challenges, such as affording medicines or mobility aids such as wheelchairs, or needed transportation to get to medical appointments. In some cases, patients with limited or no incomes needed assistance identifying and signing up for services that could help them access health care.

Case management services help patients with all these needs, aiding them in finding and accessing the care they need to become as healthy as possible. The goal is to help the patient reach full health, or the highest level of self-management possible. The case manager's knowledge of medicine combined with an understanding of the available services and products can help the patient achieve this goal.

At the same time, case management benefits those who pay for medical services, such as government agencies or health insurers, because it maximizes the results they get for the money spent on the patients' care. Through case management, payers can help eliminate wasteful spending on duplication of services. For instance, if a patient is seen by one physician and then needs to see a second specialist, a case manager can help ensure that the necessary records, x-rays, and test results are forwarded from one doctor to the other. This can help minimize the money spent on testing as well as care delays waiting for records or new test results. It also helps reduce the workload of physicians and other health care providers, freeing up resources for other patients.

Rising health care costs make case management more appealing than ever to providers and payers. At the same time, the increasing number of people living with chronic illnesses, the life-altering injuries of twenty-first-century veterans, the increased population of senior citizens, and the ability of medical science to save and maintain the lives of premature infants, cancer patients, and others who would not have survived in the past adds to the number of people who need help navigating the world of health care to maintain and restore their well-being.

Case managers generally complete an applicable college-level program in nursing, social work, or a similar field. They often pursue licensing and certification to have the widest range of opportunities. Employment options for case management can be found with government agencies, health insurers, and health care facilities.

Bibliography

Amado, Angela Novak, et al. "Research Review of Effectiveness of Case Management in the United States." Case Management: Historical, Current, and Future. Brookline, 1989, pp 1–20, mn.gov/mnddc/learning/document/GT062.PDF. Accessed 10 Apr. 2017.

"Case Management Nurse." Discover Nursing, www.discovernursing.com/specialty/case-management-nurse. Accessed 10 Apr. 2017.

"Case Management Services." Illinois Department of Human Services, www.dhs.state.il.us/page.aspx?item=33612. Accessed 10 Apr. 2017.

"Definition and Philosophy of Case Management." Commission for Case Management Certification, ccmcertification.org/about-us/about-case-management/definition-and-philosophy-case-management. Accessed 10 Apr. 2017.

Frater, Jeff. "The History and Evolution of Case Management." TCS Healthcare Technologies, 6 Oct. 2015, www.tcshealthcare.com/History-and-Evolution-of-Case-Management. Accessed 10 Apr. 2017.

Mullahy, Catherine M. and Jeanne Boling. "Case Management—The Origins, Evolution, and Future." Mullahy and Associates, www.mullahyassociates.com/wp-content/uploads/2016/04/origins-evolution-and-future.pdf. Accessed 10 Apr. 2017.

"What Is Case Management?" Case Management Society of America, solutions.cmsa.org/acton/fs/blocks/showLandingPage/a/10442/p/p-0003/t/page/fm/0. Accessed 10 Apr. 2017.

"Who We Are." Visiting Nurse Services of New York, www.vnsny.org/who-we-are/about-us/. Accessed 10 Apr. 2017.