1. ...a system for delivering care that
   
   • coordinates interdisciplinary care services,
   • plans care,
   • identifies expected outcomes, and
   • helps facilitate the patient and family
   toward those outcomes (Cesta, Tahan, & Fink, 1998).

   ---

2. A nursing care delivery system that supports cost-effective patient outcome oriented care (Cohen and Cesta, 1997).

   ---

3. A system of health care delivery designed to facilitate achievement of expected patient outcomes within an appropriate length of stay. The goals of case management are the
   
   • provision of quality health care along a continuum,
   • decreased fragmentation of care across settings,
   • enhancement of the client's quality of life, efficient utilization of patient care resources, and
   • cost containment
     
   (American Nurses Association, 1988).

   ---

4. A multidisciplinary clinical system that uses registered nurse case managers to coordinate the care for select patients acorss the continuum of a health care episode (Frink and Strassner, 1996).

   ---

5. A collaborative process which
   
   • • assesses,
     • plans,
     • implements,
     • coordinates,
     • monitors, and
     • evaluates the options and services required to meet an individual's health needs,
   • using communication and available resources to promote quality, cost-effective outcomes
   (Commission for Case Manager Certification, 1996).

   ---

6. ...(a) method of managing the provision of healthcare to members with catastrophic or high-cost medical conditons. The goal is to coordinate the care so as to both improve continuity and quality of care as well as lower costs (Kongsvedt, 1993).

   ---

1. use of a nurse case manager to identify high-risk/high-cost patients;

2. health assessment;
   [ASSESS]

3. health care planning to improve quality and efficacy;
   [PLAN]

4. procurement, delivery, and coordination of services;
   [DO or IMPLEMENT THE PLAN] and

5. monitoring of the patient's care to ensure optimum outcome
   [EVALUATE]
   (Lubkin, 1995).

Overall goals include:

1. Manage cost and quality

2. Achieve positive patient outcomes
   (Cesta, Tahan, & Fink, 1998)

Specific goals may include:

1. Optimize the client's self-care capability and increase self-care capabilities;

2. Enhance the client's quality of life, sense of autonomy, and self-determination;

3. Assist the client to adjust to and manage his or her altered health state and manage his or her symptoms;

4. Enable the client and family to implement a complex health care plan through the development of an interactive relationship with a nurse case manager who serves in an educative and supportive role;

5. prevent inappropriate hospitalizations and contain health care costs;

6. Provide quality health care along a continuum with decreased fragmentation of services acrosss many settings.
   (ANA, 1988; Bower, 1992; Shipp & Jay, 1988).

Managed Care Stakeholders

Health care consumers, providers, and payors. An ideal concept of managed care is based on an assumption of shared tension and ownership among these stakeholders.

Capitation

A method of reimbursing the health care provider or provider institution an all inclusive set fee for healthcare services for each individual in the plan, rather than paying a fee for each service encounter (the traditional fee for service method). The amount of dollars per patient per month rather than dollars per services.

Brokering

Matching need to service; not only identifying need, but determining whether the need is troublesome to the client; includes agreeing on how to resolve or minimize the need (Lubkin, 1992).

Integrated Health Care Delivery System

A health care provider, or group of health care providers, which offers a broad range of services that include acute care, a selection of intermediate care (between acute and long term, e.g., adult day care), home care, and long term care. The integrated system may offer its services on a contracted basis, especially in a capitated environment.

Other Concepts (terms)

Persons examining Case Management Models can analyze models by asking questions:

1. What or what services does the model provide?

2. Who pays for services?

3. How does payment occur?

4. What degree of responsibility for client health does the model provide (how wholistic is the model)?

• Community-Based
  [Lubkin, p. 441]
  1. broker and monitor health care services delivered in home or long-term care settings; generally focus on elderly or those with chronic or terminal illness

  2. Social-HMO: long-term care for the elderly; Medicare beneficiaries voluntarily enroll and receive all medicare services plus long-term care package including skilled nursing home and home health care services; case manager carries 60 to 80 clients

  3. private, fee-for-service; fees charged on hourly basis

  ---

• Insurance-Based
  [Lubkin, p. 442]
  1. focus is cost control

  2. case management service identifies chronic and catastrophic medical diagnoses that result in high-cost, long-term care:
     1. High-risk neonatal
     2. Severe head trauma
     3. Spinal cord injury
     4. Ventilator dependency
     5. Coma
     6. Multiple fractures
     7. AIDS
     8. Severe burns
     9. Cerebral vascular accidents
     10. Amputations
     11. Terminal illnesses
     12. Substance abuse
         (Bower, 1992)

  3. Goal is to coordinate services to control cost by avoiding:
     • dupliction of services
     • fragmentation of services

  4. Services end when:
     • reach goal of care plan
     • patient dies
     • services depelete insurance coverage (money runs out)

  5. case management enables extending services for longer time within constraint of insurance maximum lifetime benefit payout (usually $500,000 or $1 million)

  6. Evaluation of cost saving: $11 savings for each $1 spent on case management services

  ---

• Acute Care-Based
  [Lubkin, p. 443]
  • uses a critical path approach
    (time-ordered client outcomes)

  • ends case manager interaction with client at discharge from acute care

  ---

• Professional Nursing, Community-Based
  [Lubkin, p. 444]
  • developed at Carondelet St. Mary's Hospital in Tuscon, AZ

  • provides continuity of case management between acute care and home (or other non-acute care) settings

  • maintains 24 hour a day availability of case manager
    • useful for client
    • useful for capitation environment
    • useful for Integrated Health Care Delivery System

A Case Management Presentation scheduled for class on 16 March 1998.

References

American Nurses Association Task Force on Case Management. (1988). Kansas City: American Nurses Association.

Bower, K.A. (1992). Case Management by Nurses. Kansas City: American Nurses' Publishing.

Cesta, T.G., Tahan, H.A., & Fink, L.F. (1998). The Case Manager's Survival Guide: Winning Strategies for Clinical Practice. St. Louis: Mosby-Year Book, Inc.

Cohen, E.L. & Cesta, T.G. (1997). Nursing Case Management: from Concept to Evaluation. 2nd ed. St. Louis: Mosby.

Frink, B.B. & Strassner, L. (1996). Variance analysis. In Flarey, D.L., Blancett, S.S., eds.: Handbook of Nursing Case Management. Gaithersburg: Aspen.

Kongstvedt, P.R. (1993). The Managed Health Care Handbook. Gaithersburg: Aspen Publishers.

Shipp, M.K. & Jay, T.M. (1988). Case management and long term care. Caring, 7(3), 42-44.