Case management is a malleable and easily adapted model that applies to a variety of care delivery locations and systems. It is because of this flexibility that the model has been designed and implemented in various ways that respond to and meet the needs of the organizations applying it. Although case management has been used in the community setting for the longest period, it is now commonly seen as an integrated care delivery model in the acute care setting and other sites along the continuum of care (e.g., skilled nursing facilities and long-term care facilities). More and more organizations are recognizing the model's ability to manage resources while maintaining or improving quality.

Clearly the most effective models are those that provide a mechanism for managing patients across the continuum of care, thereby providing a seamless, integrated care process. In a managed care environment this is most easily done because of the integrated services inherent in a managed care system. The notion of managing patients in a variety of care settings is more difficult in payer systems in which there are no incentives for various settings to communicate and/or share resources. Managed care is traditionally viewed as a system that provides the generalized structure and focus when managing the use, cost, quality, and effectiveness of healthcare services. Managed care is the umbrella for cost-containment efforts such as case management. Case management is a process model. It is based on and contains elements of the managed care theme.

Many healthcare organizations have opted to first implement case management in the acute care setting. This accomplishes a number of things. First, it allows the organization to design, implement, and perfect its case management system in a more easily controlled environment, the hospital. Although it provides greater challenges in terms of the clinical management of patients in the acute care setting, it is still a place where team members are part of a team that is "within the walls." In fact, the term within the walls has been used to aggregate those case management models that manage patients' care during the acute care portion of the illness. Among the many applications of the within-the-walls models are a host of types using the members of the team in various role functions. In most cases the registered nurse (RN) is used as the case manager. It is the placement of the RN in the organizational structure and the associated role functions that differentiate the various models.

Case management is difficult to encapsulate because it describes many different approaches, including a patient care delivery system, a professional practice model, a defined group of activities performed by healthcare providers in a particular setting, and services provided by private practitioners (Goodwin, 1994).

TYPES OF CASE MANAGEMENT

Case management services can be provided in a variety of ways and care sites. There are basically four types: primary, medical/social, private, and nursing case management. Box 2-1 summarizes the types and the sites in which they typically occur.

Primary Care Case Management
In primary care case management the physician functions as the case manager. As case manager, the physician is responsible for coordinating and managing patient care services. Some managed care organizations (MCOs) are using nurse practitioners as primary care case managers. Nurse practitioners are able to take on this role because of their ability to function independently or under a collaborative agreement with a physician. The primary care case manager is the gatekeeper who plans, approves, and negotiates care for the patient.

In MCOs the case manager triages patients and determines their future needs and resource allocation. For example, the primary care case manager evaluating a newly diagnosed asthmatic patient will determine whether the patient needs to be seen by a specialist, in an emergency department (ED) setting, or in a doctor's office. This particular managed care function serves to control expenses by limiting the use of more expensive interventions and ensuring that they are provided in the most appropriate level of care/setting.

Medical/Social Case Management
This type of case management focuses on the long-term care of patient populations at risk for hospitalization. The needs may be either medical or social in nature, and the case manager may be a physician, social worker, or RN. In some instances the case manager will follow the patient regardless of the setting in which services are being rendered.

Private Case Management
Private case management is used for patients who fall outside the traditional patient care programs. In this type of case management an RN will either be self-employed, an independent practitioner, or work on a case-by-case basis for an MCO or other third-party payer. The private case manager is contracted for services as needed. The case manager coordinates and manages the care for the patient regardless of the setting.

Because the case manager is independent of the organization, some believe that private case managers can provide the greatest level of completely unbiased services to the patient and family. The case manager functioning under this model is not advocating for anyone but the patient. This area is perhaps the newest addition to the case management arena. Many of the private case managers hired in the 1980s were master's prepared RNs or social workers (Knollmueller, 1989). In the 1990s this trend continued with case managers who were usually clinical nurse specialists (CNSs) or social workers. Often they were paid privately by the client or subcontracted by a third-party payer. The private case manager may coordinate services for the client, advocate on behalf of the client and/or provide counseling (Clark, 1996), and manage the patient's benefits based on the insurance/health plan.

Nursing Case Management
This approach to case management uses the RN as the case manager. The RN functions as the facilitator, coordinator, evaluator, and manager of patient care services and expected outcomes.

HOSPITAL-BASED/ACUTE CARE MODELS

Acute care models are those used in hospitals, EDs, and other acute care settings (Case Manager's Tip 2-1).

Primary Nurse Case Management
This model uses the staff nurse or primary nurse in the position of case manager. In addition to being responsible for hands-on, direct nursing care, the primary nurse case manager is also responsible for the indirect nursing functions that have often been the responsibility of other members of the healthcare team. Direct nursing functions include activities such as physical assessments, medication administration, vital sign monitoring, intravenous administration, wound management, and patient/family education. Indirect functions include facilitation and coordination of services, brokerage of community services, transitional/ discharge planning, monitoring of utilization of resources, outcomes management, variance analysis, and others. In this model many of the functions that would have been traditionally handed off to other departments or disciplines are collapsed under the staff nurse case manager role.

Traditionally, the staff nurse's role has been focused on the acute care, clinical, hands-on component of the patient's illness. Some discharge planning may have been included in the job responsibilities, such as referrals to visiting nurse services. Other functions, such as utilization, continuing care placement, or patient/family education, might have been shared by others on the team. For example, utilization management would have been the responsibility of the utilization review nurse. Discharge planning and placement issues might have been managed by the social worker or the dedicated discharge planner. Patient/family education might have been shared with CNSs such as the enterostomal CNS, the pain management specialist, or the medical-surgical CNS. These professionals were often called on to provide specific clinical expertise to augment that being provided by the staff nurse.

Functions such as outcomes monitoring and variance analysis were not core components of the traditional primary nursing models. Both outcomes management and variance identification have evolved as byproducts yet important elements of case management. Traditional nursing care plans did not include expected outcomes or identification of variations from the expected outcomes. In this model, the staff nurse is expected to take responsibility for these role functions.

In some versions of the staff nurse model, the staff nurse may be given the responsibility for some of these additional role functions. However, some organizations kept role functions such as utilization management in the core department. The underlying principle of the staff nurse case manager model is that the staff nurse takes ultimate responsibility and accountability for the patient's hospital course and continuing stay needs.

The early primary nurse models were intended to place the RN in the position of being ultimately accountable for all aspects of the patient's care. The primary nursing models of the 1970s developed in response to nursing's evolution toward greater autonomy and professionalism. These responsibilities included those mentioned previously as related to the direct, hands-on care. In addition, responsibilities may have included discharge planning. Utilization management responsibilities have not been traditional elements of the primary nurse role. Unfortunately, these models were unable to manage the cost and quality issues of the 1990s (Lynn-McHale, Fitzpatrick, and Shaffer, 1993).

In the primary nurse or staff nurse case management models, different levels of responsibility are placed on the staff nurse, depending on the level of integration of other departments. For example, in a fully integrated hospital the staff nurse may be responsible for direct care and all related indirect nursing functions, including transitional/discharge planning, utilization management, variance analysis, and outcomes/quality improvement. In other cases, levels of responsibility may vary. Utilization management is the most common exception to this list, with some basic utilization functions often retained by a central department. Some of the functions may include telephone communication with MCOs or other insurers, continued stay revenues, or denials.

Despite the degree of responsibility delegated to the staff nurse, a tremendous amount of education must take place to prepare the staff nurse or primary nurse to assume these added responsibilities. The staff nurse may be responsible not only for providing care to a caseload of patients on the unit but also for managing the care of patients in other parts of the hospital, regardless of location (Davis, 1996).

The staff/primary nurse case manager model may also serve as a framework for a clinical ladder, which may be composed of several positions of increasing responsibility with the case manager as the top level. This may mean that the case manager oversees more comprehensive or complicated patients. In this model, all patients must be case managed. This is because of the reduction of other services and personnel, which means that these job responsibilities must be absorbed by the staff nurse (Case Manager's Tip 2-2).

Advanced Practice Case Management
The advanced practice case manager is an RN with an advanced practice degree; either a CNS or a nurse practitioner. The advanced practice nurse brings additional dimensions to the case manager role and a level of educational preparation not held by the majority of staff nurses. The master's prepared nurse's educational preparation has a wellness or health focus that is clinically specialized and care-continuum–based (Koerner, 1991). These nurses are also educated to bring their advanced educational skills and focus on patient/family education to the daily care of their patients (American Nurses Association, 1988).

This case management model removes the case manager from direct patient care. The case manager becomes concerned with the continuum of care and moves the patient from one phase or level of care to the next, regardless of who is providing the specific care along the way. This facilitation/coordination role may also include discharge planning and/or utilization management responsibilities, depending on how the organization has been redesigned. Members of the team continually consult with each other, and the CNS case manager provides the coordination and facilitation role to the process. It is this cadre of additional and advanced skills that makes the advanced practice nurse a prime candidate for case management (Hamric, 1992).

To use existing personnel more efficiently, the organization may convert already existing CNS positions to case managers. In this case the current role functions of the CNS must be reevaluated. For example, mandatory Joint Commission on Accreditation of Healthcare Organizations (JCAHO) continuing education functions may need to be redeployed to other staff developers. By doing so, the CNS case manager is truly freed up to perform advanced practice role functions, which may have been impossible when other job responsibilities were added onto the role.

CNS case managers can be either unit-based or diagnosis (hospital)-based. In either case they should be assigned based on their clinical specialty. If the clinical care units are specialty-oriented, with cohorted, liketype patients, then a unit-based approach may work. If not, the case manager may need to be diagnosis-based to remain within the clinical specialty, regardless of the patient's physical location.

The removal of case managers from direct patient care means that they have more time to dedicate to advanced case management functions such as outcomes management and research. They are also educated to perform these role functions. Their clinical expertise, advanced preparation including research, and a continuum of care focus are benefits that they bring to the role of case manager (Norris and Hill, 1991). The CNS case manager position allows the CNS to function in a way that is more purely a clinical specialist role than when a host of staff-development responsibilities are collapsed onto the role (Wells, Erickson, and Spinella, 1996). Because of their advanced clinical expertise, it is sometimes easier for the CNS to develop relationships with physicians that extend beyond the acute care setting. The advanced practice case manager, as part of the interdisciplinary team, may work with the team in the ambulatory setting, seeing patients after discharge from the hospital. The opportunity for the patient/family to develop a longstanding relationship with the case manager may mean greater compliance with their care regimen and more positive clinical outcomes over a longer period.

Nurse practitioners bring even more skills to the case manager role. With their ability to prescribe and discharge the patient from the hospital, the care process can be facilitated and less fragmented. The ambulatory care setting may be the most valuable place to use the nurse practitioner, particularly for those patients with chronic illnesses who are frequently accessing the healthcare system (Case Manager's Tip 3-3). The nurse practitioner's holistic approach with a focus on education and wellness may translate to reduced hospital admissions and a better quality of life for the patient in the community.

There are some commonalities and some differences between the two advanced practice roles of CNS and nurse practitioner. Case management models that integrate the two roles have been suggested (Schroer, 1991).

Commonalties between the roles include patient education, graduate-level preparation, practice, care coordination, referral, specialty practice, and autonomy. In contrast, the nurse practitioner has more of a focus on primary care, including the physical examination, history, and prescribing of medications. The title is protected by state regulations, and there can be reimbursement to primary care. The CNS is more inpatient focused and uses health promotion as a secondary consideration (Schroer, 1991).

Currently, nurse practitioners work in primary care, outpatient clinics, health maintenance organizations (HMOs), and other specialty areas. CNSs work in inpatient settings (Diers, 1993) or home care settings. The differences and similarities described may suggest the use of the CNS case manager in the acute care setting and the use of the nurse practitioner case manager in the ambulatory setting.

Utilization Review Nursing Case Management
In this version of case management, some institutions have eliminated the traditional utilization review nurse and converted these positions to case managers. The first step in this process is the transition from utilization review to utilization management. This step is both philosophical and operational. Utilization review has been a retrospective process that attempted to correct problems after they occurred. The utilization review nurse would read and review medical records to determine appropriateness for hospitalization based on the physician's and other healthcare provider's documentation. In some cases the utilization review nurse would intervene when delay occurred in the care process. For example, a delay in completion of a computed tomography (CT) scan might result in the utilization review nurse making a call to radiology to determine the cause of the delay. In these cases the nurse identified a delay once it had occurred and then tried to remedy the situation. In any case, the delay had already happened. Other functions included review of services for medical necessity and assurance that services were being provided in the most appropriate setting and at an acceptable quality standard level.

Implementation of utilization case management means that the utilization management/review functions must be picked up by the case manager. One method of implementing this model has come as a result of the hospital's simply taking existing personnel and redeploying them as case managers. Responsibilities remain essentially the same without a reengineering of other departments/disciplines. In other cases the clinical case manager is given added responsibilities that include utilization management, after which the original positions are eliminated. Another approach may be to blend the discharge planning and utilization management functions together. All versions have the goal of eliminating redundant, currently existing positions and making the care process more efficient by streamlining the process and reducing the number of steps in the completion of tasks.

If financially feasible, maintaining a small utilization management core department is beneficial. Most institutions kept few centralized utilization management staff positions as part of the case management department, while converting the remainder of the positions to case managers. Such change resulted in complete elimination of utilization management as an independent department. The blending of all of the utilization functions onto the case manager role may mean that the case manager gets completely absorbed in these functions and has less time to devote to the clinical dimensions of the role. Issues such as denial of benefits may remain within the purview of the utilization management core department. Retrospective insurance reviews may also be the responsibility of this department to reduce fragmentation and delays in the care process. The case manager should take over those functions that are most closely related to the patient's current hospitalization, including admission and continued stay reviews. As many cases as possible should be concurrently reviewed. These concurrent reviews are performed by the case manager every 3 days—or more frequently in the case of critical care areas or patients with much shorter length of stay. Among the functions performed during the concurrent review process are evaluations for severity of illness and intensity of service. Evaluation of severity of illness includes an evaluation of the patient's significant symptoms, any deviations from normal levels, or unstable or abnormal vital signs or laboratory values. Intensity of service includes evaluation of the plan of treatment, interventions, and expected outcomes. Retrospective reviews can be handled by the utilization management core staff.

Including concurrent reviews as part of the case management process can help expedite the plan more quickly. The case manager has the most comprehensive knowledge and understanding of the case and is observing it in its totality rather than in a fragmented approach. Payer interactions can also be facilitated through such an integrated approach. Benefits identification and eligibility are becoming more cumbersome processes as the number of MCOs continues to rise. Each organization brings with it a host of different benefits. Even within one MCO, similar patients will be entitled to different benefits. Negotiating these benefits for the patient while in the hospital and after discharge can mean a smoother transition for the patient from the acute care to the community setting. This comes as a result of fewer "hand-offs" of the work from one provider to another.

Caution must be taken in the implementation of such a model so as not to overload the case manager. It is highly recommended that the tasks identified previously as part of a centralized core utilization management department remain so, or the true case management focus will be lost in performing insurance reviews, dealing with denials, and so on (Case Manager's Tip 2-4).

Social Work Case Management
Social workers have used the title case manager for many years. In fact, after the RN, social workers are the other professionals most often seen in the role of case manager (Rantz and Bopp, 1996). The social worker, if functioning as the case manager, can focus on the patient's social, financial, and discharge planning needs. The social worker as case manager is effective in the outpatient setting, where many of the patient's needs are related more to financial or social issues and less to clinical ones. In the hospital setting, a dyad of RN case manager and social worker can be an effective way to manage cases based on needs. If the prevailing issues are clinical or educational in nature, the RN may be more appropriate for case management. If the patient's needs are more social or financial, the social worker may be more appropriate to provide the necessary services.

In the dyad model the RN and social worker case managers assess the patient on admission to the hospital; based on that assessment, it is determined which practitioner may be more appropriate to manage the case. In some cases it may be necessary for both disciplines to case manage the same patient.

The case manager's initial assessment would be a clinical or biological review of systems, reason for hospitalization, relevant previous medical history, clinical issues that may affect discharge, and educational needs. The social worker would be focused on the social support and psychological segments of the patient's overall clinical picture. A social assessment includes an evaluation of the patient's lifestyle, activities, interests, and support system. Family support, living environment, and the patient's ability to return to the preadmission environment would be assessed by the social worker. The psychological assessment would consist of an evaluation of the patient's mental status; use of alcohol, tobacco, and drugs; and previous history of mental disorders.

When implementing this model, it is extremely valuable for both disciplines to sit down together and outline what their case management inclusion or selection criteria will be (Box 2-2). Through techniques such as case conferencing, an ongoing evaluation can be made as to the patient's progress toward the expected outcomes and as to whether additional providers may need to be added to the case.

This type of model, although extremely patient focused and beneficial to the patient and family, may be too costly for the organization to support. If so, the RN case manager can call the social worker on a referral basis for cases needing more comprehensive social work–type interventions (Case Manager's Tip 2-5).

In an RN/social worker dyad model, another effective strategy can be the use of specific referral criteria adapted to various clinical settings. Working as a team, the nurse and social worker can meet the needs of high-risk patients identified through the use of prospectively determined criteria that reflect the specific issues identified in discreet clinical settings. If you work in a hospital or clinic setting in which a variety of types of patients are treated, it may be helpful to outline the referral criteria by clinical specialty. The examples in Table 2-1 will serve as guides only. Each organization must develop its own unique set of criteria to meet its clinical needs, as well as remain appropriate to the specific case management departmental design.

For example, the criteria for referring a social worker to a patient in the ED will vary significantly from the needs of a patient on a maternal/child unit. By using this type of criteria, both disciplines can be deployed to specific patients as needed, and in a timely fashion. In all instances, the division of responsibilities should address the unique skill sets and knowledge base of each discipline. Clinical needs should be addressed by the RN case manager, whereas social/financial needs are best addressed by the social worker. In this way each discipline's knowledge and time are optimized.

Admitting Department Case Management
Early acute care case management models did not give great attention to the two fundamental routes of entry to the hospital, the ED and the admitting department. Acute care settings now recognize the importance of gatekeeping these hospital admission points to manage and control the types of patients approved for admission. Before managed care, the need for putting such controls in place was much less obvious and clearly less important.

Case management in the admitting department provides for a gatekeeping function at one of the two primary routes of entry to the hospital. Patients are screened through the use of clinical indicators. Through this process, the patient's severity of illness and the intensity of service requirements are compared with the services being requested by the admitting physician. When the patient's needs do not meet the admission criteria (see Section 3, Chapter 1 and 2), the case manager contacts the physician to discuss care alternatives to the acute care setting.

The case manager may suggest to the physician the use of an alternative level of care/setting such as ambulatory surgery or an observation unit. It is important that the case manager never deny an admission without providing the physician with alternative settings along the continuum that would more appropriately meet the patient's clinical needs and ensure reimbursement.

The case manager also screens all admissions for which the admitting physician is requesting preoperative days. Using established criteria, the case manager will either approve or disapprove the request. If approval cannot be granted because reimbursement cannot be obtained, the case manager will communicate this to the admitting physician. If the case manager and the physician feel that a patient cannot adequately prepare himself or herself for surgery, such as completing a bowel prep, then despite the lack of reimbursement, the approval will be granted. The patient's intensity of service should be the primary indicator determining whether a preoperative day is necessary.

The admitting department case manager also screens all patients being transferred into the hospital to ensure that the transfer is appropriate and meets all Medicare guidelines. The basic rule of thumb for acute to acute transfers is that the receiving hospital should have the capacity to provide the higher level of service that the patient requires, and that cannot be provided in the transferring hospital. An example of this would be cardiac surgery. The patient may have been admitted to the sending hospital for a cardiac catheterization or on an emergency basis (e.g., acute chest pain). The sending hospital may not have open heart surgery services available, and therefore the patient must be transferred to receive this higher level of service.

Once admission to the hospital has been agreed to, the admitting case manager is responsible for communicating his or her approval to the admitting department. Generally the clerical staff in the admitting department then obtain a preauthorization or precertification from the insurance company. When the insurance company is requesting clinical information before giving its precertification, the case manager is often the appropriate person to provide that link between the clinicians, the admitting department, and the insurance company.

The admitting case manager reviews all same-day admissions before the scheduled day of surgery to ensure that preauthorization has been obtained. Additionally, the admitting case manager may be responsible for reviewing all "short-stay" medical records. These would be the medical records of patients who have been in the hospital for 24 hours or less and who were not placed in an observation status. The case manager would review the record to assess whether the care rendered and documented met acute care criteria. If the record does not support an inpatient level of reimbursement, the case manager has the authority to revert the hospital bill to the ED services only. In this way an insurance denial is avoided and the hospital is at least assured that it will receive the ED level of reimbursement in a timely manner (Case Manager's Tip 2-6).

Preadmission Testing Case Management
In some organizations the admitting case management functions may be integrated with the preadmission testing process. During the preadmission process the case manager may interview and "intake" preoperative patients. During this interview process the case manager would evaluate the patient for any preadmission issues that might affect the hospitalization or posthospitalization process. Part of this assessment should include exploring discharge planning options with the patient/family. When appropriate, the patient should be referred to the social worker who will be responsible for the patient after admission and the inpatient case manager. The case manager may also collaborate with the attending physician when postdischarge needs can be clearly anticipated. For example, an elderly patient who is scheduled for a hip replacement will most likely need either subacute or home care rehabilitation after surgery. The preadmission case manager can begin to discuss options with the patient, family/caregiver, and physician and can also explore these options with the insurance company. All intake information should be communicated to the inpatient case manager so that a smooth transition can take place for the patient. The case manager should document a "preadmit" note in the patient's record that would include postdischarge needs and options.

Perioperative Services Case Management
Perioperative case management is designed to provide case management services to surgical patients. The process begins at the preadmission phase, continues postdischarge, includes surgery and postanesthesia recovery, and terminates at the postoperative period. The perioperative case manager provides an important link between the members of the surgical team and the patient. During the preoperative phase the case manager assesses the patient to be sure that the patient is ready for surgery. Readiness may be defined by the following checklist:      

If any elements on the checklist are not completed and/or are problematic, the case manager can adjust the operating room (OR) schedule so that the patient is not left on the schedule, cancelled, and then another patient placed in that slot. For example, before surgery the patient may refuse to sign consent or may become unstable and unable to go to surgery the next day.

Perioperative case managers can also review same-day surgical admissions to ensure that the minimal requirements for surgery have been completed. They use the American Surgical Association (ASA) classification system (Box 2-3) as the review criteria in addition to any other utilization management criteria as indicated by the organization or the managed care companies. For example, for ASA I and II categories a history and physical must be completed, as well as a complete blood cell count (CBC), electrocardiogram (ECG), chest x-ray examination, and PT/PTT when indicated. For ASA III and IV, all of these must be completed, the patient must be assessed by an anesthesiologist, and any additional tests as indicated by the patient's primary care physician must be completed. For example, a patient with hypertension may need additional testing before the medical clearance will be approved.

The perioperative case manager maintains a vital link between the patient, the surgeon, and the OR schedule. Potential delays or cancellations are identified earlier, and adjustments are made to the OR schedule so that OR time can be optimized every day. By identifying potential problems early, the patient can be reassessed and possibly go for the surgery later on the day scheduled rather than the surgery being cancelled, resulting in a potential denial of payment by a third-party payer.

COMMUNITY-BASED CASE MANAGEMENT MODELS

Community-based case management encompasses any of the case management functions that are being performed outside the acute care setting. Community-based case management, whether in the home care arena, the clinic setting, or the chronic care setting, is designed to support patients and families in achieving the optimal level of wellness by accessing and using community services. Community-based case management incorporates a focus on the continuum of care.

In some instances the community-based case manager provides episodic case management. For example, the home care case manager manages the care of a patient through a specific episode of illness, after which his or her span of responsibility concludes. The community-based case manager, working out of a clinic setting for a patient in a capitated, at-risk contract, may follow this patient from enrollment to disenrollment, passing the case management "baton" to the episodic case manager (e.g., the acute care or home care case manager [Box 2-4]).

Home Care Case Management
Case management in the home setting is designed with the same goals in mind as case management in the acute care setting. The role of home care in the success of case management is critical, especially because of the ability to care for increasingly complex and chronically ill patients. The implementation of chronic care management and disease management programs have provided a unique opportunity for home care case management to reduce the need for acute care services, therefore allowing healthcare providers and executives to curtail cost and reduce the hospital's length of stay. The continuum approach to case management programs and managed care have also spurred alternative approaches to the provision of healthcare services, such as subacute care, transitional living centers, infusion centers, day treatment centers, and especially sophisticated home care services that handle individuals requiring higher and alternative levels of care and acuity (Case Manager's Tip 2-7). The goals of home care case management are as follows:

The demand for case managers to coordinate and integrate healthcare services in the home setting has increased exponentially over the past decade. This has resulted from the growth of managed care, increasing capitation, implementation of the home care prospective payment system by the federal government for Medicare and Medicaid beneficiaries, demand management programs, integrated delivery systems, and the payers' expectations that the providers do more for less. The case manager in the home environment directs the members of the interdisciplinary healthcare team (Box 2-5) toward the achievement of the bestquality care at the lowest possible cost (Case Manager's Tip 2-8). The home care case manager also makes visits to patients in their homes to ensure that they are receiving the appropriate services and that the expected outcomes are being met. During the home visit the case manager may decide to refer the patient to the physician or other healthcare providers as deemed necessary.

The home care case manager receives referrals from the hospital-based case manager. The home care case manager can obtain important information on the patient's condition and related care by visiting the patient in the hospital and/or attending the hospital patient planning or discharge planning rounds. If a face-to-face exchange of information is not practical or possible, then the home care and hospital case managers must develop good systems for the sharing and exchange of information. Information to be shared should include the patient's medical history, physical symptoms and functional abilities or other findings, financial information including entitlements, and relevant psychosocial issues, including family support mechanisms (Brueckner and Glover, 1993).

Patients receiving home care services are not acute enough for hospitalization and are not ambulatory enough for daily visits to a clinic setting or physician's office. In most cases the cost of home care is a fraction of what a hospital stay would cost. In addition to monitoring the patient's progress during this phase of illness, the case manager will also ensure that the necessary services are being delivered in the home setting and that the patient's optimal level of wellness is being met. Under fee-for-service (FFS) reimbursement, there was no financial incentive for the home care agency to control the number of home visits. Just as hospital visits were relatively unlimited before the prospective payment system, the home care agencies are only now beginning to face reductions in resources and reimbursement for visits. Under capitated managed care and the prospective payment structure, the number of home visits are the most strictly controlled.

The criteria for selecting patients for the provision of home care case management services are similar to those of traditional home care services and defined by the conditions of participation in Medicare and/or Medicaid programs. In order for the patients to receive home care case management services, they must meet the following criteria:

Research has shown that a variety of factors may influence home care nurses' decisions regarding management of their clients, including the appropriate number of visits or the necessity for referrals to social service or other agencies (Feldman et al, 1993). Home care agencies have developed home care protocols similar to those previously developed for hospital care (e.g., pathways and multidisciplinary action plans [MAPs]). These prospectively developed tools become the case manager's frame of reference as they outline the appropriate number of visits for a particular disease entity or surgical procedure. Expected outcomes for each discipline are predetermined so that the number of patient care visits correlates with the expected outcomes. As a result, allotted visits are not arbitrary but can be validated, and the patient's progress toward these expected outcomes can be benchmarked. The termination point for the case is also clearly defined, and the expectations of the staff in terms of when to close the case are delineated. Cases kept open beyond the appropriate length of time become very costly to the home care agency. By prospectively identifying the criteria for case closure based on outcomes, the care provider no longer has to make a subjective decision regarding when to close the case. Closing cases in a timely fashion allows resources to be appropriated to those cases that truly need extended services beyond the norm.

Home care case managers can be assigned by disease entity or broader clinical specialty. Chronic illnesses, such as diabetes, asthma, human immunodeficiency virus (HIV) and AIDS, or congestive heart failure, may require case management services in the home after an episode of acute exacerbation of the disease. Rehabilitation after joint replacement is another clinical grouping for which case management may work well. These patients will require the services of more than one discipline, such as nursing and physical therapy. By coordinating these services and monitoring the patient's progress closely, the case manager can ensure that the patient is moving toward those outcomes as efficiently as possible without duplication or redundant utilization of resources (Case Manager's Tip 2-9).

Community-Based Nursing Case Management
Community-based case management models are focused on primary care and primary prevention. They are therefore predominantly focused on healthy individuals in the community who are at risk or who have the potential for needing healthcare services. These models can provide integrated services found nowhere else. Comprehensive, coordinated, community-based programs can interrelate the client's health, social, educational, employment, and recreational needs.

Community nursing centers are defined as those in which the key management positions are filled by RNs. These centers can range in size from a staff of one to 115 RNs, with an average of eight per agency (Barger and Rosenfeld, 1993). Some centers use a case management model and philosophy to guide the care delivery process. In nurse case management models, the practice may be an autonomous nursing one. Two thirds of the RNs employed in nursing centers are certified for advanced nursing practice (Barger and Rosenfeld, 1993). Nurse practitioners are able to provide primary care as the client's first contact with a healthcare provider. The remaining practitioners are generally master's prepared social workers. Referrals are made to on-site and off-site physicians and other off-site healthcare providers. Other resource referrals may be on or off site.

The goal of community-based case management is to support and empower individuals to maximize their optimal level of wellness through the use of community resources (Case Manager's Tip 2-10). Health promotion may be incorporated into activities such as day care classes, youth and adult recreation programs, support groups, meals for elders, community development activities, and adult education programs.

Both formal and informal mechanisms can be used to provide case management services. These might include nonscheduled walk-in clinics, scheduled appointments, home visits, or telephone consults. All are focused on continuous rather than episodic care (Trella, 1996).

The community-based case manager can provide other important services to the patient, such as continuing the educational program initiated in the hospital setting. Patients in the hospital may not retain the information they learned as a result of anxiety or pain and may therefore benefit greatly from reinforcement on returning to the community. The community-based case manager discusses topics the patient has been taught in the hospital and continues the educational process through repetition, reinforcement, or continuation of teaching related to the specific topic.

The ongoing education and support provided by the community-based case manager may mean that exacerbations of the patient's disease and/or readmissions can be reduced. Many programs are focused around specific disease entities such as diabetes, chemical dependency, or HIV. These programs are geared to already diagnosed individuals whose goal is to maintain their optimal level of wellness in the community for as long as possible.

Community-Based Social Work Case Management
Community-based social workers may perform a variety of functions. Generally, a social work model is predicated on some form of referral process whereby the social worker is referred cases that are deemed to be at high risk. High-risk criteria for a community-based social work referral might include such things as the need for psychosocial counseling/support, family counseling, financial counseling, and stress management. Social workers in the community may be referred patients through a physician, a clinic, or through self-referral

In some high-risk cases, a patient may be case managed by both a nurse and a social worker in the community. The need for both disciplines is determined based on the patient's high-risk needs. Those with both psychosocial and clinical needs may therefore be case managed by both a nurse and a social worker. In this way, the neediest patients receive the care and support of the disciplines best able to meet those needs.

Social workers in the community may provide short-term psychosocial interventions or long-term support, depending on the needs of the patient and family. For example, a family with a child who has cystic fibrosis may need years of psychosocial intervention and support. The social worker may maintain a therapeutic relationship with that child and family for a very long time.

Subacute Care Case Management
The subacute setting is among the fastest growing care delivery settings within the continuum of care. The reasons for this growth are obvious. Just 10 years ago it was not uncommon to find patients recovering in acute care beds for weeks on end while receiving nothing more than an intravenous (IV) antibiotic, wound care, or ventilator weaning. Because of the high cost of managing these types of patients in acute care beds, MCOs began to expect that patients meeting the clinical criteria of subacute would be transferred to subacute units, whether in hospitals, nursing homes, or freestanding facilities.

Subacute care is considered restorative, meaning that it is expected that the patient's condition will improve as a result of the care rendered. The level of care is somewhere between acute care and traditional nursing home care. Care rendered may be less invasive and less diagnostically oriented as compared with acute care. In comparison with traditional nursing home care it is more intensive and of shorter duration. The average length of stay is generally between 7 and 30 days. Admission criteria would be specific to the program of care, such as neurologic, rehabilitation, or orthopedic, and the patient would have to demonstrate clear outcome potential.

In the subacute setting the physician would visit 1 to 3 times per week. Average nursing care is 4.5 to 8 hours of direct nursing care per patient day, with a high use of nurse aides. To qualify for subacute rehabilitation, typically a patient must be able to tolerate a minimum of 1 to 1½ hours of therapy per day. Patients are expected to be discharged home after the course of treatment.

Case managers who discharge patients to subacute settings must be familiar with the criteria for the levels of service in the subacute setting.

The three categories include

(1) short-term rehabilitative or restorative,
(2) short-term complex medical or recuperative, and
(3) long-term, chronic, or preventive maintenance (Table 2-2).

The hospital-based case manager should always consider transferring a patient to a subacute level of care/setting when the acute care outcomes have been met and the patient's care can be rendered in a less intensive setting.

The case manager in the subacute setting coordinates the services of the interdisciplinary team that would include physicians, therapists, nurses, and other professionals such as nutritionists. The case manager is responsible for ensuring that the patient is moving toward expected outcomes of care, whether restorative, recuperative, or end of life. In some instances the patient may be discharged home to continue with home care services, or the patient may need to be moved to a skilled nursing facility level of service. By closely monitoring the patient's progress toward expected outcomes, the case manager can assess that the patient is receiving the appropriate level of service, and if not, the case manager should work with the interdisciplinary team to transition the patient to the appropriate level or to home if outcomes have been met.

Nursing Home/Long-Term Care Case Management
Patients with any diagnosis can be admitted to a skilled nursing facility level of service. Care is considered to be either chronic or supportive. The average length of stay is approximately 1½ years. Physician visits are about once a month, and patients receive about 1½ to 3 hours of nursing care per patient day. Rehabilitation services provided to the nursing home resident are limited in scope and when provided are usually less than 30 minutes per day. Patients leave this level of service either when admitted to a hospital or at the time of their death.

As in the subacute setting, the long-term care case manager can provide a vital link between the members of the interdisciplinary team.

Emergency Department Case Management
As a commonly used route of entry to the hospital, acute care case management models should not neglect to staff this important hospital department. As does the admitting department case manager, the ED case manager provides an important gatekeeping function for the hospital. The ED case manager is responsible for facilitating the patient's hospitalization from preadmission through discharge from the ED. The case manager interfaces with physicians, nurses, social workers, and other members of the team to expedite medically appropriate, cost-effective care.

The ED case manager manages different groupings of patients. These include the treat-and-release patients; patients admitted to the hospital; patients who can be discharged from the hospital but will require follow-up services, such as home care, in the community; observation patients; and inappropriate admissions such as social admissions.

Treat-and-Release Patients
This group of ED patients will receive all necessary services during their short-term treatment time in the ED and will be discharged without the need for follow-up home care or other community services beyond the routine follow-up physician or clinic appointment. The ED case manager can assist these patients to receive the care they require in the most expeditious way possible. Patients who typically fall into this category include asthmatics or those with other chronic illnesses and patients with injuries or viruses, colds, and the like. Because of the common misuse of EDs in the United States, many of the treat-and-release patients could have received the care they needed in their primary care physician's office or an urgent center.

The case manager facilitates the initiation of diagnostic services, treatment plans, and therapeutic treatments while the patient is in the ED. The case manager identifies any delays in service and either expedites the process by eliminating barriers or collaborates with other members of the interdisciplinary team to resolve the problem.

Patients Admitted from the Emergency Department
The case manager works with the interdisciplinary team to facilitate diagnostic testing in the ED and to ensure that the treatment plan is initiated immediately once a diagnosis has been rendered. For example, a pneumonia patient who is being admitted to the hospital should have his or her antibiotic therapy initiated while still in the ED once the diagnosis has been established. By initiating the treatment in the ED, hours can be shaved off the length of stay and quality of care is enhanced.

The case manager also works with the team to ensure that the patient is transferred to the inpatient bed as quickly as possible. Patients who are out of their managed care network may choose to be transferred to a hospital within their network. The case manager plays an important role in identifying these patients and discussing their options with them. Patients can only be transferred by their own request and if stable. So as to not violate any Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, the case manager should only inform the patient that if they are admitted they may risk some financial responsibility for the hospital bill. The case manager should make it very clear to the patient that they have every right to remain and that they will receive appropriate care, but that there may be some financial risk associated with this decision.

Case managers working in EDs must have a working knowledge of EMTALA and its requirements. EMTALA (also known as COBRA, Section 1867, or the Federal Antidumping Act), governs the delivery of all hospital-based emergency medical care in the United States. It is an antidiscrimination statute.

Two sections in EMTALA relate directly to the initial interactions of EDs with managed care patients, or the "Appropriate Medical Screening Examination" (MSE) requirement, and the "No Delay on Account of Insurance" provision.

The Appropriate Medical Screening Examination provision states the following:

If any individual comes to the emergency department and a request is made on the individual's behalf for examination and treatment, the hospital must provide an appropriate medical screening exam within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists (42 USC 1395dd[a]).

For the case manager in the ED, this simply means that all patients who come to the ED must be given an appropriate medical screening. Patients cannot be turned away for any reason. Case managers should be sensitive to this provision and should never be pressured to transfer a patient to another facility unless by the patient's request and only after an appropriate medical screening.

The No Delay on Account of Insurance provision states the following:

A hospital may not delay provision of an appropriate medical screening examination or necessary stabilizing treatment... in order to inquire about the individual's method of payment or insurance status (42 USC 1395dd[h]).

It should never be the policy of an ED to demand that a patient receive authorization from his or her managed care company before screening takes place. The ED case manager should never interfere in this process. In any event, a managed care company cannot deny authorization for an ED visit under any circumstances unless once triaged it is determined that the presenting condition is not an emergency condition. Under those circumstances, the patient's care may be delayed while authorization is being obtained. The patient may be referred to his or her urgent care center for further treatment of the non-emergent complaint.

If the patient requires hospitalization and is out of network, the ED should have a written procedure for informing the patient of the potential "financial risk" of being admitted to the out-of-network hospital. The patient should be clearly told that he or she may certainly stay at the out-of-network hospital if he or she so chooses and that the patient will receive all needed services if that is his or her decision. At the same time, the patient should know that this decision may result in his or her suffering some financial burden such as a deductible or a copayment, depending on the patient's coverage. If the patient chooses to transfer to an in-network hospital, the patient must sign a release indicating that he or she is transferring at his or her own request. The patient's plan should be billed for the transportation to the in-network hospital. Under no circumstances can a patient be transferred unless he or she is medically stable. Transfer would also be appropriate under circumstances in which the patient needed transfer to receive a higher level of service than was available in the first hospital.

Emergency Medical Conditions
Under EMTALA, the definition of an emergency medical condition (EMC) is much broader than typical medical usage. An EMC is any condition that is a danger to the health and safety of the patient or unborn fetus, or may result in a risk or impairment or dysfunction to the smallest bodily organ or part if not treated in the foreseeable future, and includes the following range of conditions:

The ED case manager plays an important educational role for the hospital and an advocacy role for the patient and should remain cognizant and up-to-date on EMTALA at all times.

The ED case manager performs an intake assessment on admitted patients and communicates this assessment to the inpatient case manager. The assessment should include a discharge planning assessment and referral to the social worker if necessary. The case manager should provide any clinical information needed by the third-party payer during the admission process.

Discharged Patients with Services
The case manager in the ED is responsible for coordinating any needed follow-up services for patients returning to the community. In some instances, this intervention may prevent an unnecessary or nonreimbursable admission. The case manager will coordinate the discharge plan with the team and ensure that the services are covered by the patient's third-party payer. Once this has been completed, the case manager will facilitate and coordinate those services with the community agency. Typically, patients who fall into this category will need home care services. On occasion a patient may be transferred to a long-term care facility directly from the ED. In all instances the case manager should follow established criteria to ensure that the patient is receiving the appropriate level of service.

Observation Patients
Under Medicare, observation is an outpatient category in which the patient needs observation of a condition or following a procedure for less than 24 hours. Patients may be observed in a specific observation unit or scattered within the hospital. If the patient is placed in an inpatient bed, the patient's status remains outpatient and the bill should reflect that this level of care was provided. The hospital may bill the third party for the ED visit and for up to 24 hours after the time of transfer from the ED. Under the ambulatory payment classification (APC) system, the observation portion of the stay will be bundled with the ED APC and an enhanced rate should be reimbursed.

The ED case manager should work directly with the attending medical staff in the ED and assist them in the identification of patients appropriate for observation. The InterQual and Milliman and Robertson criteria both provide the clinical parameters of the observation status.

Inappropriate Admissions
When it is clear that a patient does not require admission, the case manager should assist the care team in identifying an alternative care regimen appropriate to the needs of the patient. For example, a patient may require admission to a long-term care or subacute setting or may require home care services. Working with the patient, the family and the care team, the case manager can facilitate the movement of the patient to the appropriate level of service and prevent a hospital denial of payment.

SYSTEM MODELS

The system models are designed to provide case management services along the continuum. A continuum of care is defined as an integrated, client-oriented system of care composed of both services and integrating mechanisms that guides and tracks clients over time through a comprehensive array of health, mental health, and social services spanning all levels of intensity of care (Evashwick, 1987). The continuum contains seven access points to healthcare, as described in Box 2-6.

The case manager is assigned to the case at one of the seven access points, depending on where the patient enters the healthcare system. In most cases the case manager is responsible for the patient no matter where the patient is along the healthcare continuum. This may mean that the primary case manager communicates with the case manager in the setting in which the patient currently is. For example, if a community-based case manager is following the patient, the responsibility for the case may be relinquished to the hospital-based case manager should the patient be admitted. The community-based case manager would share relevant information with the hospital-based case manager and might visit the patient. The ultimate responsibility for the management of the case while the patient is in the hospital would be the hospital-based case manager's.

In organizations in which the service line crosses the continuum and there are multiple service programs, patient referrals and continuity of care are not necessarily automatic. In fact, the more complex the organization, the greater the need for client referral and tracking mechanisms (Evashwick, 1987). Continuity can be maintained by the case manager for clients at any point along the continuum (Case Manager's Tip 2-11).

CHRONIC CARE CASE MANAGEMENT

Chronic conditions are those the patient is expected to have for years or possibly for the rest of his or her life. These individuals may access and use a variety of healthcare services in a multitude of settings during the course of their illness. It is the use of these various services and settings for the chronically ill that places them at risk for receiving less-than-adequate, duplicative, fragmented, or delayed healthcare services. Typical target populations for chronic care case management include the frail elderly, survivors of strokes, accident victims, the mentally ill, and children and infants with congenital abnormalities (Evashwick, 1987).

Patients with chronic illnesses may access a wide range of services from acute care to social services, mental health, home care, or subacute care. It is during these transitions that the greatest opportunity for problems may arise. Case management integrates these wide-ranging services so that care delivery, financing, and information are integrated. It provides a foundation for planning and managing care across settings (Case Manager's Tip 2-12). The focus is more than just providing the patient with access to the various services; it is also geared toward integrating these systems to provide a coordinated, continuing care approach.

The patient population at greatest risk for chronic care needs is the elderly, particularly the frail elderly. This group is at high risk for complex health needs, potential for physical or social complications, and continued use of costly healthcare resources. A multidisciplinary approach such as that provided by a case management model has been documented to reduce cost and improve outcomes for this population (Trella, 1993). The application of case management to this population may mean providing adult day care programs with transportation. The children of aging parents may be able to maintain their parents in the community if they have access to an adult day care program that provides a flexible structure so that they can drop parents off on their way to work and pick them up in the evening. Other necessary services may be meal preparation, delivery services, housekeeping, or shopping services (Mullahy, 1995).

LONG-TERM CARE CASE MANAGEMENT

Long-term care settings such as the nursing home, rehabilitation facility, or skilled nursing facility are settings in which case management can serve the purpose of slowing the deterioration process and functional status of the resident. In long-term care settings, care has been task oriented (Smith, 1991), with different practitioners providing different services to the resident. Today's typical nursing home patient is sicker, requires more complex medical and nursing care, and will live longer.

Increasing focus is also being placed on other subacute care settings as managed care drives the need for less expensive care settings appropriate to the needs of the patient (Stahl, 1996). Conditions that usually are considered subacute are listed in Box 2-7.

Short-term complex medical problems would include problems such as wound care, respiratory management, total parenteral nutrition, dialysis, intravenous therapies, and postsurgical recovery. The goal in case managing this group of patients is recuperative. The expected outcome is to bring the patient to the optimal level of wellness.

Short-term rehabilitative subacute care focuses on clinical issues such as stroke, amputation, total hip/knee replacement, and brain injury. The case management goal for this clinical group is restorative, to bring the patient as close to the preinjury condition as possible.

Long-term (chronic) case management is preventive maintenance, assisting the patient to maintain the level of functioning without deterioration for as long as possible. Long-term chronic conditions include coma, ventilator dependence, and head injury.

In response to these changes, nursing homes are adapting and undergoing modifications to the way they provided care in the past. Case management has been used as a mechanism not only for improving patient outcomes in long-term care settings but also for improving job satisfaction of care providers in these settings (Deckard, Hicks, and Rountree, 1986). With the introduction of a case management model, a healthcare provider can coordinate the services provided by nursing assistants, RNs, physical and occupational therapists, and nutritionists. Integrating these services and identifying interdisciplinary expected outcomes allow the resident's functional status to be closely monitored and managed. Care is managed using an interdisciplinary approach, and therefore goals can be more specific, realistic, and measurable. Furthermore, the move away from a task-oriented approach means that goals are patient-focused instead of staff-focused (Smith, 1991).

The case manager in the long-term care setting may not be an RN if there is a lack of RN staff in the facility. In some cases it may be necessary to use the licensed practical or licensed vocational nurse in the role of case manager. The case manager provides for ongoing monitoring and evaluation of the resident's progress. Progress is measured against an assessment of the patient's medical problems, functional capabilities, social supports, and psychosocial well-being (Zawadski and Eng, 1988).

Case management plans (see Section 4, Chapter 3) can be used to manage the care and expected outcomes. Plans should focus on such things as nursing needs, therapies, ADLs, and personal care (Case Manager's Tip 2-13). The chronicity of the residents may mean that the case management plans are reviewed at a maximum of every 3 months or whenever the resident's condition or change in progress warrants a review. The case manager provides an ongoing evaluation process and liaisons between the resident, the physician, the family, and other members of the healthcare team.

MANAGED CARE MODELS AND CASE MANAGEMENT

Managed care is a broad, expansive term covering a wide variety of services. Its main objective is to contain costs by controlling utilization and coordinating care. It is used as the generic term for insurance plans offering managed healthcare services to an enrolled population on a prepaid basis such as capitation (per-member-per-month fixed rate). Access, cost, and quality are controlled by care gatekeepers. The gatekeeper is usually a physician in primary care. This physician, after assessing the patient, will determine whether the patient needs additional services such as a specialty physician or other service controlled by the MCO. There are many types of MCOs, but the most common is the HMO. The four basic models are the group model HMO, the staff model HMO, the individual practice association (IPA) model HMO, and the network model HMO (see Section 2, Chapter 1).

In the various managed care models case managers are employed to carry out a variety of functions. Broadly speaking, the case management functions can be classified as either financial case management or clinical case management. The financial case manager functions in what might traditionally be classified as utilization management. This case manager is in communication with the hospital case manager or utilization manager determining the patient's admission eligibility; continued stay; or discharge disposition, including eligibility of postdischarge services. The case manager in this role advocates on behalf of the MCO and may have a caseload of hundreds or thousands of patients. This role is based on a lower intensity–higher volume approach (Sampson, 1994).

Some MCOs supplement the patients being followed by a financial case manager with a more clinically focused case manager. These case managers tend to have a somewhat smaller caseload (Sampson, 1994). Their focus is more high intensity–low volume in nature. They may be assigned by degree of risk stratification (i.e., low, moderate, or high-risk patient population) as identified by the MCO. These may include such things as catastrophic illness or injury, high-user or high-volume members, chronic or disabling conditions, or cases with high annual cost projections ($25,000 to $50,000) (Hicks, Stallmeyer, and Coleman, 1993). It is hoped that assisting in the management of these patients will prevent unnecessary admissions to the hospital and minimize misutilization of healthcare resources (Case Manager's Tip 2-14).

MCOs vary in how they employ the services of case managers. Some have developed case management departments and hired salaried case managers to assume the financial and clinical roles discussed previously. Others have contracted with independent case management entities for these services (Mullahy, 1998) (e.g., outsourced this function). Still others have a hybrid arrangement in which most case management activities are performed by the MCO while workers' compensation and long-term disability cases are subcontracted to an independent or private case management provider. However, it is unlikely for a large MCO to outsource this important function. Regardless of the arrangement, the role of the case manager remains basically the same.

Some MCOs are focusing on the management of their older members. The elderly are at greater risk in terms of cost, chronicity, and frequency of care needs. It is hoped that case managing this population will enhance the health status of older adults while containing their use of healthcare resources (Pacala et al, 1995). MCOs have employed special strategies for managing the care of this population, such as telephonic case management and triage services.

Telephonic Case Management
Member services in MCOs (HMOs and preferred provider organizations [PPOs] alike) take place mostly via telephone communication. However, other methods of communication such as paper mailings still exist to some degree, and new ones such as the use of the Internet for electronic mailings are being developed and implemented (Case Manager's Tip 2-15). Regardless of the method employed, communication between the payer, the provider, and the members is an important subject in managed care and case management. The focus on the continuum of care in case management and disease management practices and in demand management programs sponsored by MCOs has led to an expansion in the role of the case manager. New additions include responsibility for interventions or functions that are based on the telecommunication advances such as telephone triage and telephonic case management.

Telephonic case management is defined as the delivery of healthcare services to patients and/or their families or caregivers over the telephone or through correspondence, fax, e-mail, or other forms of electronic transfer (Siefker et al, 1998). It is a patient and family encounter with a healthcare provider, in this case a case manager, applying the case management process (see Section 1, Chapter 3) to appropriately meet the patient's needs. It also is considered a cost-effective and proactive strategy for preventing catastrophic health outcomes and high expenses associated with major illness events. Box 2-8 contains additional benefits to telephonic case management.

Telephonic case management services exist across the continuum of care, particularly in the following settings:

Although health advice lines have been in existence for quite some time, they did not become popular for the delivery of case management services until recently. This newer form of case management, known as telephonic case management, is the result of the pressures on managed care for cost containment and improved and timely access to healthcare services. However, MCOs incorporated telephonic case management services as an additional benefit to their members in the form of telephone triage. This service, when provided by the payer, focuses on the financial management (utilization management and resource allocation) aspect of case management. Today, the clinical aspect of case management is as popular as financial management. However, this is generally a focus of the provider rather than the payer.

Case managers provide telephonic case management services in a variety of forms and around the clock. The managed care case manager focuses on triage services and utilization management. The clinical case manager focuses on the coordination and integration of clinical services as they are needed by patients. Both types of case managers use algorithms, guidelines, or protocols for the delivery of case management services. These guidelines provide the case manager with prospectively developed plans of care that incorporate decision-making steps in the form of decision trees. For example, a mother may call the telephone triage line for an advice regarding her 3-year-old child, who is suffering from a high fever.

The case manager engaged in this telephone conversation will bring up the pediatric fever algorithm on his or her personal computer. The case manager will use this algorithm to guide the assessment and evaluation of the child's signs and symptoms so that he or she can determine the urgency of the child's medical/health condition and the type of advice or intervention he or she will be providing. Depending on how urgent the situation is, the case manager will advise the mother to

(1) give the child a dose of Tylenol,
(2) continue to observe the child and bring the child to the pediatrician's office, or
(3) bring the child to the nearest ED.

In this example, the case manager would provide clinical case management advice and triage the patient to access the appropriate level of care/setting for further healthcare services. Other types of interventions are based on the type of call received. Telephone calls made to the MCO case manager are mostly related to problems with claims, clarifications of benefits, authorizations of services, or triage. Those made to clinical case management programs usually focus on the provision of advice, patient and family education, counseling, health risk management, self-care management skills building, and in some instances triage or brokerage of services. In both types of interventions, case managers apply a process of assessment of the situation/need, analysis of the situation using a related algorithm/protocol, prioritizing/determining the urgency of the situation and planning care, implementing care strategies, and evaluation of the outcomes (Blanchfield, Schwarzentraub, and Reisinger, 1997).

In telephone triage, case managers use their findings of the assessment they complete for each caller to categorize the call (i.e., the patient's condition) into one of three triage categories: emergent, urgent, or nonurgent (Rutenberg, 2000; Van Dinter, 2000).      

In deciding on the triage category, the case manager considers the patient's age, gender, past medical history, medication intake, and access to care (Rutenberg, 2000). When uncertain of a caller's situation, case managers may consult with a physician or nurse practitioner or may refer the patient/caller to them (Van Dinter, 2000).

Independent/Private Case Management
Independent/private case management entails the provision of case management services by case managers who are either self-employed or are salaried employees in a privately owned case management firm. They are known as "external" case management services. The terms independent and private refer to the absence of oversight by an MCO or a healthcare organization such as a home care agency or an acute care hospital (Case Manager's Tip 2-16). An insurance company or a healthcare facility usually subcontracts with independent case managers for the provision of case management services, particularly for long- and short-term disability cases. However, a patient or a family member may subcontract case management services from a private case manager for assistance in the coordination of cost-effective and appropriate care, for example, to the chronically ill elderly member of the family (Case Manager's Tip 2-17). Because the structure and services are almost the same in both independent and private case management, their descriptions in this section will be combined.

Independent/private case management focuses on enabling the patient to make the necessary transitions along the healthcare continuum and to successfully navigate the healthcare delivery system. It also focuses on monitoring resource utilization, managing costs and health benefits, and ensuring the provision of quality care and services. Healthcare organizations and MCOs are more likely to subcontract with an independent/private case management firm in the areas of rehabilitation and disability case management than for other clinical services. Subcontracting of such services is considered more cost-effective and thought to increase patient and family satisfaction. In these arrangements, case managers manage the care of their patients as representatives of the insurance company or healthcare facility unless they are hired directly by the patient or family, in which case they represent the patient.

The goals of independent/private case management are similar to other case management programs/models, particularly the insurance-based models. They include the coordination and facilitation of complex medical services; ensuring the provision of timely, quality, and appropriate services; cost-effectiveness; reduction of fragmentation or duplication of services; and providing the patient/family with a one-to-one personalized relationship with a case manager.

Independent/private case managers may not always receive referrals for their patients at an early stage of illness, trauma, or disability. On the contrary, most often they receive a referral after a patient has been ill or disabled for an extended period, which causes the illness to be considered chronic rather than acute and the focus of care to be rehabilitation and restoration of function rather than curative.

Although in independent case management the insurance company or healthcare facility hires the case managers, they are required to obtain certifications for services from the MCO before they are provided to the patient. Therefore independent case managers are usually seen interacting with the managed care–based case manager on an ongoing basis. They even provide concurrent and periodic review of the patient's condition, progress, and treatment plan to the managed care-based case manager. Usually these reviews are set to occur at a predefined time interval and are discussed. Ongoing authorizations of services are also required every 30 days regardless of whether new services are implemented. The same expectations apply for private case management unless the patient/family who made the arrangement for care is paying privately (self-paying) for the services.

Workers' Compensation
Case management approaches to workers' compensation have been implemented to curtail the increased cost and reduce the potential for legal litigation. They are even more important today because of the shift in workers' compensation insurance to a managed care structure in the form of HMOs and PPOs and their related utilization management practices. The application of case management in workers' compensation provides another example of the value of case management services and evidence that such models exist across the continuum of care. \Workers' compensation, also known as "workers' comp," is a type of insurance employers are mandated by law to offer to their employees in the event of an on-the-job injury (Case Manager's Tip 2-18). It is a no-fault system of benefits for employees who sustain occupational injury or illness (DiBenedetto, 2001). According to DiBenedetto, a person must sustain the injury or illness while on the job and must incur medical costs, rehabilitation costs, lost wages, or disfigurement to qualify for workers' compensation benefits. Employers are mandated by law to provide their employees with three types of benefits: indemnity cash benefits in lieu of lost wages, reimbursement for necessary medical expenses, and survivors' death benefits (Powell, 2000).

Workers' compensation claims are the result of trauma or job-related illness. Case management is an effective strategy used to expedite the return of injured employees to work. Case management services must be directed toward bringing the injured employee to maximal medical improvement and physical functioning and eventually back to work. Case managers are essential for meeting these goals. They assume the responsibility for coordinating medical care and rehabilitation services. They also facilitate the resolution of legal issues by acting as liaisons between the injured employee, legal representatives (lawyers), occupational health department, claims adjusters, and employer. Case managers achieve these goals by following the injured employee from the time the injury occurs until a safe, maximal, modified, or optimal return to work takes place (DiBenedetto, 1999). During this time they collaborate with rehabilitation professionals in the development, implementation, monitoring, and evaluation of the employee's plan of care and return-to-work plan.

The main focus of case management services in the field of workers' compensation is return to work. The case manager develops and achieves the return-to-work plan through the application of the case management process and in collaboration with the injured employee, the employer, and the physician(s) and other healthcare providers involved in the employee's care. Return-to-work plans are of three types (Case Manager's Tip 2-19): full, modified, or temporary. Full plans aim at returning the injured employee to a full work assignment and schedule similar to that which existed before the injury. Modified plans are those adjusted to meet the injured employee's abilities and physical limitations resulting from the injury. Case managers implement these plans to expedite the employee's return to work (Box 2-9). Temporary plans are those that are adjusted for a limited period during the time the injured employee is still undergoing rehabilitation. These plans include limitations in job functions based on the medical and functional condition of the employee. Before the employee returns to work with this temporary plan, human resources or occupational health services must approve the work schedule and assignment (DiBenedetto, 1998).

Case managers are effective in achieving these plans if they build trusting and humanistic relationships with the injured employee. They must treat their patients with courtesy, dignity, and respect. These relationships are important particularly because injured employees tend to disengage themselves from the work environment. This act of disengagement presents case managers with a greater challenge when facilitating an employee's timely return to work. The process may be delayed if the case manager is not successful in reengaging the injured employee with the work environment, and this cannot be achieved unless the case manager is able to build an effective relationship with the employee (Vierling, 1999).

Disability and Rehabilitation Case Management
The application of case management models for disability and rehabilitation management resulted from escalating costs of medical care, rising premiums, and other costs related to lost time from work and litigation of workers' compensation cases. It also became of greater demand because of the use of managed care insurance health plans by employers and the increased number of patients with complex, traumatic, and catastrophic injuries that required intensive short- or long-term disability and rehabilitation services. Employers usually refer their workers' compensation cases for comprehensive case management services because of their desire to control cost and improve the quality and continuity of care provided for this population.

Disability case management is defined as a process of managing occupational and nonoccupational diseases with the aim of returning the disabled person to a productive work schedule and employment (Powell and Ignatavicius, 2001). Occupational diseases are the result of injury on the job or illness caused by the work environment. Nonoccupational diseases are health conditions (e.g., trauma caused by an automobile accident) that are not related to the work environment but result in short- or long-term disability that prevents return to work for a period of time and sometimes indefinitely (DiBenedetto, 1998). The disability case management process involves the application of the concepts and strategies of workers' compensation case management and the rehabilitation treatment modality. Case managers in disability case management models focus on limiting the disability by coordinating and facilitating immediate medical interventions once an injury or illness occurs and by facilitating the referral process to rehabilitation providers and specialists. The ultimate goal of care and services is to return the patients to work and to restore optimal level of functioning and independence as soon as possible.

Disability case managers possess special training and expertise in the management of short- and long-term financial, psychological, sexual, physical, social, and vocational consequences of an illness or injury. Successful rehabilitation and cost-effectiveness result from the use of case managers who are specialized in the care of catastrophic injuries and disability insurance and claims management. Many employers and disability insurance companies employ the services of this type of case manager as soon as a catastrophic injury occurs because the earlier the case management services start, the better the financial and medical care outcomes (Hosack, 1998).

Because of the benefits of disability and rehabilitation case management services, we find case managers today working in almost every catastrophic injury specialty center. The focus of case management in these centers is similar to that of external case managers (i.e., private and independent) in the following areas:

SETTING UP THE CASE MANAGEMENT PROGRAM

The following can be used when setting up a program in any setting across the continuum. As you move forward with your design and implementation, be sure you have addressed each of these points. Keep a running list for yourself and/or the committee working on the project to ensure that all relevant questions have been addressed. Each point can be addressed in any order, but be sure that each question is answered before the implementation of the program (Case Manager's Tip 2-20).

Creating the Department
Cost Implications/Budget
Develop a business plan. The plan should include both personnel and nonpersonnel costs needed to run the department. Consider all staff needed, including professional staff and support staff such as secretarial and clerical staff.

Also consider equipment needed, such as fax machines, photocopiers, and computers. Cost this out as part of the business plan. Set up a budget with the annualized cost of running the department.

Staff (Professional/Secretarial/Clerical Support)
Staffing should be based on the role functions to be performed. For example, RN case manager to patient ratios will be driven by the functions the RN is performing. If the RN case manager is performing clinical coordination/facilitation, transitional planning, and utilization/quality management functions, an appropriate caseload in the hospital setting would be 1:20. The number of case managers needed can then be calculated based on the bed capacity of the hospital.

Other staffing ratios should also be driven by the size of the organization and the functions to be performed.

Equipment and Supplies
The time to budget for equipment and supplies is before the implementation while the budgetary costs are being determined. Consider all functions being performed and the hardware and software needed to support those functions. Also consider the management needs and report writing capability when selecting a software package. Other supplies that should be budgeted for include stationery, paper, telephone lines, transportation, and conferences.

Table of Organization/Reporting Structure
Develop a table of organization for the department with a clearly differentiated reporting structure. Also consider where the department will fit into the organization and to whom the director of the department will report. Of significant importance is the case manager. The table of organization must clearly state where the case manager's position is and to whom he or she reports. This statement is essential for empowering those who assume the case manager's role.

Hours of Operation
The hours of operation of the department may be driven by budgetary constraints. Decisions will need to be made as to whether the department will operate 7 days a week or will function 5 or 6 days. Perhaps you will consider having the ED staff working longer shifts (such as 12 hours) while the inpatient staff work 8-hour shifts. Consider the clinical needs of the organization and the goals of the department when making these decisions. If there is a considerable amount of activity on the weekends, operations on the weekends must be planned for.

Relationships to Other Departments
The department may have either formal or informal relationships to other departments in the organization. Consideration should be given to how these relationships will be defined. You may want to consider an oversight committee that would be composed of leadership staff from related departments, such as admitting, medical records, patient accounts/billing, radiology, pharmacy, and so on.

Policies and Procedures
A policy and procedure manual should be developed and should include all policies and procedures needed to define the functions of the staff. For example, if utilization management is one of the functions of the department, then all appropriate utilization review policies should be included. Consider any JCAHO requirements when developing the manual. Include the table of organization and the staff job descriptions, training, and competencies in the manual. Also important to have on hand for use by case managers is a resource manual that has contact information readily available, particularly for community resources, volunteer agencies, charity and shelter services, transportation services, and skilled nursing/long-term facilities.

Information Technology/Systems
If the budget permits, select computer hardware that is state of the art and that will support the functions you are performing both now and in the future. For example, if one of the goals of the department is to eventually become paperless, be sure that your system will support this goal. In terms of case management software products, try to view and test several products before making your selection. Be sure that the software can store and manipulate all of the data needed, especially variance data, for reporting purposes for the department.

Educating the Organization
Before implementation, set up a series of educational programs. Programs should be conducted for case management staff at an in-depth level and for other staff on a less detailed level. Provide additional focused education to the medical staff and administrative staff as needed. Educational programs should be geared toward the needs of the different nursing, medical, and allied health staff.

Developing the Case Manager's Role
The following issues should be considered when designing the role of the case manager (Case Manager's Tip 2-21).

Role Functions
Careful consideration must be taken when defining the role functions of the case manager. Depending on the role functions selected, other departments may need to be restructured or eliminated. Consider all of the functions discussed in this chapter and match these to the goals and objectives of the department and the organization. If staff members from restructured or eliminated departments are used as case managers, they should be provided with special training. In addition, conducting teambuilding sessions for these staff members is advisable to work out any concerns they may have.

Integration with Other Departments/Disciplines
In some instances, other departments may become integrated with the case management department. Typically these may include social work and/or quality management. A physician staff member may also need to be integrated, such as a physician advisor. All related departments should be consulted as these decisions are being made, and appropriate staff should be trained accordingly.

Job Descriptions
Job descriptions should be completed before the implementation of the department. As staff are interviewed and hired for these new positions, they should have an opportunity to review the job description and expectations for the position for which they are interviewing. Be sure to include all job functions, skills, performance expectations, and expected outcomes of the position. A job clarification exercise is usually helpful in determining who is best suited to assume responsibility for what functions.

Management Versus Union
If your organization is unionized, a decision will need to be made as to whether the case manager position will be in or out of the union. There are pros and cons to each position, but the ultimate decision will probably be dependent on the structure of your organization and its relationship with the union. It may be difficult to justify keeping the position out of the union if the case managers do not perform any of the functions typically considered as management functions, such as hiring/firing and evaluation of other staff.

Service Line Versus Unit-Based
The case managers can be assigned to specific product/service lines or clinical areas or be unit-based. They may also be assigned to physician groups or geographical areas, depending on whether your department is in the hospital or in the community. This decision will ultimately drive your staffing patterns and needs. Decisions must be made carefully because of their impact on performance, productivity, and the possibility of ending up with unnecessary unproductive time such as travel time between units, departments, or different locations.

Reporting Structure
A strong infrastructure is important to the success of a case management department. Be sure that the case managers have a clear line of authority and are well supported as they perform their functions.

Staffing Patterns/Case Loads
A typical mistake made when designing case management departments is to not provide the proper staffing patterns to support the role functions selected. Be sure that the caseloads are not so great that the case managers cannot perform their functions effectively or efficiently. This will surely be a formula for failure. Staffing patterns should also depend on whether you go with service line case managers or unit-based case managers, patient acuity levels, and length of stay.

Hours of Operation
Select hours of operation that best meet the operational needs of the department and the patients. Increase the number of staff at busier times, and decrease the number of staff at quieter times. Consider evening, weekend, and holiday needs. Hours of operation should be adjusted to the needs of different care settings and patient populations.

Clinical Practice Guidelines
The format for the organization's clinical practice guidelines should be determined before startup of the department. In this way the case management staff can begin developing the guidelines as soon as the department is implemented.

Variances/Delays
A variance identification system should be developed before implementation. Categories of variances such as patient, system, and practitioner should be selected, as well as a methodology for collecting, coding, aggregating, analyzing, and reporting of variances.

Documentation
Frequency of case management documentation and expected content should be determined and included as a policy and procedure for the case managers. Each organization needs to determine its own specific expectations for documentation while considering JCAHO, National Committee on Quality Assurance (NCQA), Commission on Accreditation and Rehabilitation Facilities (CARF), Utilization Review Accreditation Commission (URAC), and other regulatory requirements for documentation.

Orientation
Curricula for orientation of case management staff, other departments, physicians, and administrative staff should be developed, and education should take place before implementation. This will ensure greater organizational support because the reason for the changes will be understood by all involved.

Goals and Objectives
Departmental goals and objectives should be identified before implementation and included in the educational programs. The goals and objectives selected should be consistent with the vision and mission of the organization. These may include measures of cost such as cost per day/cost per case and measures of quality patient outcomes. All should be prospectively identified and should drive the evaluation of the program.

KEY POINTS

1. There are four basic types of case management, using RNs, physicians, or social workers as case managers.
2. Hospital-based models generally use the RN as case manager, but the RN can be a primary nurse, CNS or nurse practitioner, or utilization review nurse. In some cases the case manager may be a social worker.
3. In some hospital-based models, the RN case manager performs the function of utilization management.
4. In RN/social work dyad models, the two disciplines work as an integrated team.
5. Outpatient case management models can be applied in home care, the community, or along the continuum.
6. Some models focus on management of the chronically ill.
7. Long-term case management can take place in the subacute setting, rehabilitation facility, or chronic nursing home setting.
8. Managed care models use the case manager as either a utilization manager or clinical manager acting on behalf of the MCO.
9. Telephonic and independent/private case management are considered "external" case management services.
10. All case management models must be designed to promote quality care in a fiscally responsible manner.

Appendix A
Appendix B
Appendix C
Appendix D
Appendix E-1 Appendix E-2 Appendix E-3
Appendix F
Appendix G
Appendix H
Appendix I
Appendix J
Appendix K
Appendix L
Appendix M
Appendix N
Appendix O


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