Do Program Directors Care About StatPearls? Understanding Case Management in Modern Healthcare

Case management stands as a vital healthcare process, expertly designed to aid patients in navigating the complexities of the healthcare system. A dedicated professional guides the patient in creating a comprehensive plan that synchronizes and integrates necessary support services. This coordinated approach aims to optimize healthcare delivery and achieve the best possible psychosocial outcomes.[1] Effectively, case management simplifies the intricate web of services available within health plans, institutions, and communities, making it easier for patients and their families to access and utilize them. The importance of case management is underscored by the statistic that a small percentage of patients disproportionately account for a large portion of healthcare spending. Studies reveal that approximately 10% of patients are responsible for about 70% of healthcare expenditures, and a similar pattern is seen in emergency department usage, where 5% of patients may account for 30-50% of visits.[1, 2] These high-utilizing patients often struggle to independently manage their healthcare needs, leading to inefficient and costly healthcare utilization, characterized by over-reliance on expensive emergency services and underutilization of coordinated, effective care.

Case management is frequently intertwined with related healthcare activities such as care management, care coordination, and disease management. While these terms often overlap, case management is a foundational component of each. Care management is a broader term, particularly in payer contexts, encompassing a wide array of services beyond just healthcare-related aspects. It includes access to lifestyle programs, recreational activities, and social enrichment, all within the scope of a patient’s benefits plan.[3]

Care coordination, similarly, builds upon case management but operates within a larger programmatic framework. It’s often discussed in population health strategies, where organizations aim to manage the diverse needs of patient populations, often identifying subgroups who would benefit most from case management services.[3] Disease management, in contrast, represents a more focused application of case management, targeting specific patient groups sharing a common diagnosis or condition. Programs for patients with arthritis or those recovering from joint replacement surgery are examples of disease management initiatives offering specialized support for a defined period.[3] Professionals in these roles are sometimes referred to as service brokers, service coordinators, or system navigators, highlighting their role in guiding patients through the healthcare system.[4]

The healthcare journey is often compared to travel, and case managers are seen as travel companions, agents, or guides. These metaphors emphasize their central role in helping patients chart their course through the healthcare system, ensuring they have the necessary support and direction to reach their health goals.[4]

Alt text: A case manager in a suit assists a senior patient in a wheelchair, highlighting patient support.

The components of case management are multifaceted. Drawing from descriptions by organizations like the Case Management Society of America and the National Case Management Network of Canada, core elements include patient identification and eligibility, comprehensive assessment, care planning and goal setting, plan implementation, ongoing monitoring, and seamless transitions and discharge.[2] These core elements are consistently highlighted in various summaries of case management processes.[3, 4] However, the scope of case management can extend beyond these core components, incorporating a wider range of activities and tasks.[3, 4]

A comprehensive literature review by Lukersmith et al. analyzed 79 articles, identifying 22 definitions of case management, 5 distinct models, and 17 key components, further broken down into 69 activities and tasks that build upon the foundational six core elements.[5] This variability in definition and scope can sometimes lead to a lack of clarity and potential role confusion among professionals involved in case management. The 17 key components identified in the review include: proactive case finding, establishing rapport with patients, comprehensive assessment, strategic planning, system navigation, direct provision of care, plan implementation, interdisciplinary coordination, continuous monitoring, rigorous evaluation, feedback mechanisms, patient and family education, advocacy, supportive counseling, administrative tasks, discharge planning, and community service development.[5]

Given the broad nature of case management as both a concept and a set of activities within healthcare, it can be viewed from numerous perspectives. Health insurers, hospitals, health systems, physician practices, and community health organizations all utilize case management. It can be applied to diverse patient populations, from primary care patients with chronic conditions to more specialized groups facing specific clinical challenges, such as brain injury. The case management process spans from initial patient identification and engagement through assessment and care plan development, culminating in ongoing monitoring and achievement of measurable outcomes. At its heart, case management centers on creating a tailored care plan – a roadmap guiding the patient through their healthcare journey.

Key Challenges in Defining Case Management

The expansive nature of case management, encompassing a wide array of activities, makes it challenging to define as a precise, discrete intervention. Adding to this complexity is the variability in definitions and the diverse clinical settings where case management is practiced. Lukersmith et al.’s review highlighted the use of case management across various service sectors, including health, social services, correctional facilities, vocational rehabilitation, veterans’ services, and legal aid.[5] Service settings are equally diverse, ranging from public and private institutions to non-governmental organizations, each with varying levels of resources and support.[5]

The intensity and duration of case management involvement can also vary significantly. It can range from brief, episodic interactions, such as those provided after an inpatient orthopedic procedure, to long-term, holistic support for patients with severe mental health disorders receiving care from community-based organizations over many years.

This evolving and broad scope of case management has resulted in inconsistent definitions and varied interpretations of what constitutes a case management intervention. This ambiguity is frequently reflected in the literature. A systematic analysis by Hudon et al., examining 21 articles and 89 related documents, identified at least five distinct service delivery models classified as case management within healthcare settings.[6] Lambert et al. describe the current body of literature on case management as a “black box,” suggesting that its complexity and variability in practice and definition warrant considering it as an unfolding process – a series of interconnected actions within a complex, adaptive healthcare system.[7]

The Clinical Significance of Case Management

Case management unfolds over time and is fundamentally built on the relationship between the patient, the case manager, and the various healthcare providers and organizations involved in the patient’s care. The process is operationalized through the six core elements of case management, tailored to each patient’s unique clinical context. These core elements are embedded within the more extensive list of 17 components identified by Lukersmith et al. and are further described below.[5]

1. Patient Identification and Eligibility Determination: This initial step involves proactively identifying patients who could benefit from case management services but are not currently receiving them. Building rapport is crucial, establishing a strong interpersonal connection between the case manager and the patient.
2. Assessment: A comprehensive assessment aims to develop a deep understanding of the patient, encompassing their healthcare and social needs, their strengths and capabilities, and the resources available to them within their family and community.
3. Care Planning and Goal Setting: Planning involves creating a detailed care plan that outlines treatment goals, specific actions required to achieve those goals, access to necessary services and supports, and clearly defined, measurable outcomes tailored to the patient. Navigation is a key aspect, where the case manager guides the patient through the healthcare system, proactively addressing anticipated or unexpected barriers. In some settings, particularly in mental health, the case manager may also be directly involved in the provision of care, such as offering counseling or skills training as part of the therapy team.
4. Plan Implementation: Implementation is the stage where the care plan, with its diverse activities and tasks, is put into action. Coordination, while related to navigation, is broader in scope, encompassing the facilitation of interactions and communication among various care providers, service settings, organizations, and institutions, with the patient at the center of this coordinated effort.
5. Plan Monitoring: Monitoring is an ongoing process throughout case management, involving continuous feedback and follow-up to assess the effectiveness of the care plan and track progress toward desired outcomes. Evaluation occurs at specific milestones to formally assess whether the care plan is helping the patient achieve their goals. Feedback mechanisms ensure that service providers receive information about the effectiveness of their services, contributing to ongoing improvement. Providing education and information is essential, empowering patients and their families to understand relevant health topics and healthcare processes. Advocacy involves activities aimed at empowering patients to access services, supports, and accommodations to which they are entitled. Supportive counseling provides consistent encouragement and emotional support as the care plan progresses. Administration encompasses the necessary documentation, report writing, data collection, and analysis integral to modern healthcare systems.
6. Transition and Discharge: Transition planning prepares the patient for movement across different points in the healthcare continuum, based on their health status and service needs. This may involve transitioning home or to another care facility. Discharge marks the point where the case management process concludes, as goals have been met, and the patient no longer requires active case management. Community service development is an important outcome; when case management reveals unmet needs or service gaps within a community, the case manager can advocate for and help create new services or supports to address these gaps.

Ultimately, case management is about empowering patients to effectively coordinate and navigate their healthcare in a cost-effective manner. Hudon et al. identified five key patient-centered outcomes: improved self-management skills, better care plan adherence, increased patient satisfaction, improved self-reported health status, and enhanced perceived quality of life.[6] They also noted system-level benefits, including reduced healthcare overuse and costs, and improvements in measured quality of care. Earlier research by Hudon et al. highlighted a range of positive outcomes spanning both patient and system-oriented parameters, including improved health status, functional status, patient satisfaction, self-management abilities, reduced emergency department visits, fewer clinic visits, decreased hospital admissions, shorter hospital stays, and lower inpatient costs.[1]

Studies indicate that positive outcomes are more likely in case management interventions characterized by high intensity, such as small case-loads, frequent face-to-face interactions, and in-person initial assessments. Furthermore, interventions involving multi-disciplinary and inter-organizational care plans are also associated with better outcomes.[1]

Alt text: An interprofessional healthcare team collaborates in a meeting, emphasizing teamwork in case management.

The core function of case management is to assist patients in coordinating and navigating their healthcare journey. The development and implementation of a relevant and practical care plan is central to this process. When effectively followed, this plan guides patients toward their health goals, leading to positive health outcomes, improved functional capacity, enhanced wellness, and greater self-management skills. Ultimately, case management strives to improve the overall quality of life for the patient.

Interventions by Nursing, Allied Health, and Interprofessional Teams

Case management, with its inherent focus on coordination, is deeply rooted in multi-disciplinary communication and teamwork.[8] An effective case manager must be adept at facilitating communication across various disciplines to create a comprehensive care plan that integrates the expertise of all relevant fields involved in a patient’s care. This is particularly crucial for patients with chronic conditions or those who frequently utilize healthcare services. Case managers interact with a diverse patient population, each with unique backgrounds, capabilities, and levels of family and community support.

Nurses and social workers are often recognized as ideal professionals for case management roles due to their clinical experience and training in communication and teamwork.[9, 10] Specific clinical areas may also benefit from the expertise of other allied health professionals. Occupational therapists bring valuable skills in rehabilitation settings, while psychologists contribute significantly in behavioral health contexts.[4, 11] Clinical experience is consistently recognized as a valuable asset in training effective case managers. A baccalaureate degree in nursing is generally considered a minimum educational requirement, with a master’s degree being preferred and often seen as optimal for advanced practice in case management.[10]

References

1. Hudon C, Chouinard MC, Pluye P, El Sherif R, Bush PL, Rihoux B, Poitras ME, Lambert M, Zomahoun HTV, Légaré F. Characteristics of Case Management in Primary Care Associated With Positive Outcomes for Frequent Users of Health Care: A Systematic Review. Ann Fam Med. 2019 Sep;17(5):448-458. [PMC free article: PMC7032902] [PubMed: 31501208]
2. Hudon C, Chouinard MC, Aubrey-Bassler K, Muhajarine N, Burge F, Pluye P, Bush PL, Ramsden VR, Legare F, Guenette L, Morin P, Lambert M, Groulx A, Couture M, Campbell C, Baker M, Edwards L, Sabourin V, Spence C, Gauthier G, Warren M, Godbout J, Davis B, Rabbitskin N. Case management in primary care among frequent users of healthcare services with chronic conditions: protocol of a realist synthesis. BMJ Open. 2017 Sep 03;7(9):e017701. [PMC free article: PMC5589014] [PubMed: 28871027]
3. Ahmed OI. Disease Management, Case Management, Care Management, and Care Coordination: A Framework and a Brief Manual for Care Programs and Staff. Prof Case Manag. 2016 May-Jun;21(3):137-46. [PubMed: 27035084]
4. Kanter J. Clinical case management: definition, principles, components. Hosp Community Psychiatry. 1989 Apr;40(4):361-8. [PubMed: 2714749]
5. Lukersmith S, Millington M, Salvador-Carulla L. What Is Case Management? A Scoping and Mapping Review. Int J Integr Care. 2016 Oct 19;16(4):2. [PMC free article: PMC5388031] [PubMed: 28413368]
6. Hudon C, Chouinard MC, Aubrey-Bassler K, Muhajarine N, Burge F, Bush PL, Danish A, Ramsden VR, Légaré F, Guénette L, Morin P, Lambert M, Fick F, Cleary O, Sabourin V, Warren M, Pluye P. Case Management in Primary Care for Frequent Users of Health Care Services: A Realist Synthesis. Ann Fam Med. 2020 May;18(3):218-226. [PMC free article: PMC7213991] [PubMed: 32393557]
7. Lambert AS, Legrand C, Cès S, Van Durme T, Macq J. Evaluating case management as a complex intervention: Lessons for the future. PLoS One. 2019;14(10):e0224286. [PMC free article: PMC6822731] [PubMed: 31671116]
8. Waite A, Carson J, Cullen D, Oliver N, Holloway F, Missenden K. Case management: a week in the life of a clinical case management team. J Psychiatr Ment Health Nurs. 1997 Aug;4(4):287-94. [PubMed: 9362831]
9. Moore ST. A social work practice model of case management: the case management grid. Soc Work. 1990 Sep;35(5):444-8. [PubMed: 2237522]
10. Strassner LF. The ABCs of case management. A review of the basics. Nurs Case Manag. 1996 Mar-Apr;1(1):22-30. [PubMed: 9157936]
11. Robinson M, Fisher TF, Broussard K. Role of Occupational Therapy in Case Management and Care Coordination for Clients With Complex Conditions. Am J Occup Ther. 2016 Mar-Apr;70(2):7002090010p1-6. [PubMed: 26943102]