#1. First and foremost, what is a case manager?
The definition of case management has evolved over a period of time. While there are many definitions, the 2009 definition of case management approved by CMSA (Case Management Society of America) is as follows:
"Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality cost-effective outcomes".
The basic concept of case management involves the timely coordination of quality services to address a client's specific needs in a cost-effective manner in order to promote positive outcomes. This can occur in a single health care setting or during the client's transitions of care throughout the care continuum. The case manager serves as an important facilitator among the client, family or caregiver, the health team, the payer, and the community.
Case managers are recognized experts and vital participants in the care coordination team who empower people to understand and access quality, efficient health care.
#2. Will I be doing mostly paper-work?
At the core of case management we have one mission: Patient-Centered Care.
Case management practice extends across all health care settings, including payer, provider, government, employer, community, and the home environment. However the practice varies in degrees of complexity and comprehensiveness based on the following four factors: (Powell and Tahan, 2008).
1. The context of the care setting, such as wellness and preventions, acute, or rehabilitative.
2. The health conditions and needs of the patient populations served, as well as the needs of the family or caregivers, such as critical care, congestive heart failure, renal failure, hospice care.
3. The reimbursement method applied, such as managed care, workers' compensation, Medicare, or Medicaid (MediCal).
4. The health care professional discipline designated as the case manager, such as registered nurse, social worker, physician, rehabilitations counselor, etc.
The roles assumed by case managers vary based on the above four factors. The role tends to consist of several functions and each function is described through a list of specific activities. These descriptions constitute what is known as a "job description" (Tahan, Huber, Downey, 2006).
Role functions of case managers include:
- Conducting a comprehensive assessment of the client's health and psychosocial needs, including health literacy status and deficits, and develops a case management plan collaboratively with the client and family or caregiver.
- Planning with the client, family or caregiver, the primary care physician/provider, other health care providers, the payer, and the community to maximize health care responses, quality, and cost-effective outcomes.
- Facilitating communication and coordination between members of the health care team, involving the client in the decision-making process in order to minimize fragmentation in the services.
- Educating the client, the family or caregiver, and members of the health care delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, case management, etc., so that timely and informed decisions ca be made.
- Empowering the client to problem-solve by exploring options of care, when available, and alternative plans, when necessary, to achieve desired outcomes.
- Assisting the client in the safe transitioning of care to the next most appropriate level.
- Striving to promote client self-advocacy and self-determination.
- Advocating for both the client and the payer to facilitate positive outcomes for the client, the health care team, and the payer. However, if a conflict arises, the needs of the client must be the priority.
#3. What is the job market for case managers?
There is an ever growing need for case managers as evidenced by healthcare institutions employment opportunities across the United States. Research shows where case managers are used; health care quality goes up while the costs go down. In this win/win situation, is there little wonder why more and more businesses and health care companies are utilizing case managers? A variety of inpatient and outpatient settings are offered. Please see the answer to #4 to see a list of settings where case managers are used.
#4. Do I have to work as a case manager immediately?
With an advanced nursing degree, you may choose to work in a variety of settings.
While most inpatient case managers have a minimum of 2 years experience as a bedside nurse, some graduates are finding they transition to case management within the first year. In the outpatient setting, there are opportunities for immediate employment upon graduation. The following is a list of settings where case managers exist.
- Hospitals and integrated care delivery systems, including acute care, sub acute care, long-term acute care facilities, skilled nursing facilities, and rehabilitation facilities.
- Ambulatory care clinics and community based organizations, including student university counseling and health care centers,
- Public health insurance programs, Medicare, Medicaid (MediCal), state-funded programs.
- Private health insurance programs, workers' compensation, occupational health, disability, liability, casualty, automotive, accident and health, long-term care insurance, group health insurance, managed care organizations.
- Independent and private case management companies
- Government-sponsored programs, correctional facilities, military health care, Veterans Administration, public health.
- Provider agencies and community facilities, mental health facilities, home health services, ambulatory and day care facilities.
- Geriatric services, including residential and assisted living facilities.
- Long-term care services, including home and community based services.
- Hospice, palliative, and respite care programs.
- Physician and medical group practices.
- Life care planning programs.
- Disease management companies.
#5. What is the future of case management?
The consistent delivery of quality health care services and the high financial cost generally associated with those services are important concerns that touch everyone, from our leaders in Washington, D.C. to the American public. Payers continue to seek methods for reducing costs while advancing quality and transparency. Providers explore methods to define and report quality while maximizing reimbursement. Too frequently, the health care consumer is left to navigate the health care system without the tools, resources, support or education that are vital to this role. Although a number of strategies for health care reform have been espoused and debated, case management has emerged as an important intervention that fosters the careful shepherding of health care dollars while maintaining a primary and consistent focus on quality of care and client self-determination.
Case management is an advanced practice within health care that serves as a foundation for patient centered care. Minimizing fragmentation in the health care system, using evidence-based guidelines in practice, case management is essential to improving quality and safety while saving resources throughout the continuum of health care.