Case management is an approach to managing care and service delivery to meet client needs in the most cost-effective manner. Case management activities have the potential of saving money, improving effectiveness, and maintaining the quality of care. According to Daniels & Ramey (2005), case management is a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual’s healthy needs through communication and available resources to promote quality cost effective outcomes. The goals of case management include the achievement of optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s right of self-determination (Anonymous, 2010).
Case Management Programs in Reducing Costs or Improving the Quality of Care
Case management programs are more concerned with reducing costs of care. This is because according to Nagelkerk (2005), case management programs are designed to coordinate care, decrease costs, and facilitate outcomes of cost. Anonymous (2010) argues that it involves coordination of services and sequencing of care for optimal outcomes using the available resources. Case managers sequence and organize services from many departments within the organization and are accountable for good financial and clinical outcomes (Anonymous, 2009). For example if a managed care organization has a capitated, or per diem, financial arrangement with the provider, the organization is more willing to support less expensive setting for care delivery.
The degree, to which objectives are attained, rather than the simple completion of tasks, marks the strength of a hospital case management program. Daniels & Ramey (2005) state that the way objectives are achieved is what differentiates one hospital’s case management program from others. Case management programs are more concerned with reducing costs of care, because they reduce variations in the resource consumption among CHF and CABG cases and lower costs per discharge by 5% for the top five surgical diagnostic categories. Nagelkerk (2005) also claims that case management encompasses coordination of services and sequencing of care for optimal outcomes using available resources.
Case management programs are more concerned with reducing costs of care, because it ensures good resource utilization achieved through protocols or critical pathways derived from the research and evaluation of patient outcomes (Nagelkerk, 2005). Case management programs promote cost effectiveness because they facilitate and encourage better decision-making process regarding the essential strategies that improve the scope of access to health care services while reducing cost (Anonymous, 2010).
The Limitations of a Typical Case Management Program and Their Strengths
One of the major limitations of case management is that differences among the client groups, served as well as contextual factors, such as financial incentives and features of the service system, can affect implementation of case management program (Roberts, 2009). The second limitation is that although internal case management programs can have greater potential influence based on their formal and informal relationship with key decision makers and providers, they may lack the objectivity and autonomy that are main aspects of external programs when choosing interventions and services for the patients (Anonymous, 2010).
The first strength of case management programs is that as healthcare costs continue to increase, it has been embraced by individuals, organizational, and governmental payers, as an effective approach to cut costs, and recent studies have shown improved efficiency and effectiveness (Roberts, 2009). The second strength of case management programs is that they offer an approach that is capable of coordinating multiple systems of care to enhance quality while reducing fragmentation and costs. The third strength of case management is that it promotes service coordination, integration, and brokerage, as well as the use of preventive services, such as wellness and health promotion programs (Anonymous, 2010).
It is important to note that as healthcare systems track their goals of promoting client contentment, nurturing client loyalty, and becoming vital to the community, case management is becoming the dominant strategy selected by these systems to meet their goals. Anonymous (2010) says that this is a major strength, because the increased benefits for the healthcare consumers will support and subsidize the future development of wellness models of case management.
The Necessity of Case Management Programs in Future Medical Program
Case management programs will become a medical program necessity in future. This is because given the complexity of the healthcare system and the variety of hospitals, where case management is practiced, it is likely that a single, unified conceptual model of hospital case management will suffice (Daniels & Ramey, 2005). There is a need to create a case management model specific to the medical programs in healthcare organizations, which, when put into action according to each hospital’s preferences, will construct a solid foundation, upon which to expand experiment and excel. In future, medical programs will require case management programs to enable healthcare leaders to think in terms of the ways each part of the case management program will interact with other parts of the program and with the realities of the hospital system (Daniels & Ramey, 2005).
Case management program will becomea medical program necessity in future, because currently, it is common in programs serving older adults, whether publicly or privately funded. Roberts (2009) noted that the current state of home and community based services is the product of public policy development process. Individuals meeting eligibility criteria for home and community based services have complex care needs, requiring systematic and comprehensive assessment and individualized care plan (Anonymous, 2010). As a result, in the future case management will be crucial, so as to respond to the complexity of client circumstances and the problematic state of the healthcare delivery system. Care planning is also a key resource allocation process and a critical case management function (Anonymous, 2010).
The need for case management programs will be integral to future medical programs because customers are demanding an integrated interdisciplinary health care system that provides comprehensive care from birth to death, not just in case of events of care during hospitalization (Anonymous, 2010). To respond to the challenges of guaranteeing access and affordability of care, many hospitals will be required to establish formal initiatives for monitoring, measuring, and managing clinical processes (Mullahy, 2008). The initiatives are often found in the form of hospital case management programs.
The Importance of Gatekeepers to the Case Management Process
Gatekeepersensure the completion ofpatient care activities in a timely fashion and the use of resources in an appropriate way and based on the needs of patients (Cohen & Cesta, 2005). Gatekeepers collaborate with the interdisciplinary team members to meet patient’s needs and the goals of treatments. Anonymous (2010) notes that case managers act as gatekeepers to coordinate and facilitate the provision of care on a day to day basis. Cohen & Cesta (2005) state that in the case management process, gatekeepers facilitate a timely delivery of care and patient’s movement through the complex health care system in order to reduce fragmentation or duplication of care activities and to promote a collaborative practice atmosphere among the various care providers.
Gatekeepers prevent any delays in patients’ discharge, and help to control the length of stay and resources; hence, costs. This role responsibility makes gatekeepers important in the case management process, because they acquire the reputation of being able to get the things done (Cohen & Cesta, 2005). Health care providers then seek gatekeepers out every time a problem arises or a certain care activity is not getting done. Cohen & Cesta (2005) claim that it is easier for the nurse case managers to assume the role of gatekeepers for patient care coordination and facilitation in the case management process, because of their understanding of the operations of the institution, the existing systems, and the policies and procedures.