THE PATIENT PROTECTION AND Affordable Care Act (ACA) includes three primary goals: to decrease the cost and increase the availability of health insurance, to expand Medicaid, and to foster innovation of low-cost healthcare delivery models.1,2 Many healthcare organizations have utilized case managers as a means of achieving these goals.3 This article discusses the role of case managers in the healthcare setting.
With the advent of accountable care organizations (ACOs), which are groups of physicians, hospitals, or healthcare providers that offer high-quality, coordinated care, the ACA has led to a boom in case management.4 According to the Commission for Case Management Certification (CCMC), the number of case managers rose from 27,000 in 2010 to 42,000 in 2017.3 CCMC also reported that 32% of case managers work in ACO settings and that nurses make up to 89% of certified case managers.3 Of all professional case managers, 67% have been involved in the profession for more than 10 years and 28% have advanced degrees.3 These professionals are typically seasoned nurses who value continuing education (see Case manager certification requirements).
Defining the profession
Case managers are defined consistently across different professional organizations. According to the Case Management Society of America, case managers “meet an individual's and family's comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes.”5 The Code of Professional Conduct for Case Managers states that these healthcare professionals support the Institute for Healthcare Improvement's Triple Aim of improved patient-care experiences, reduced healthcare costs, and improved population health.6,7
Case managers work to meet patient needs through assessment, coordination, and planning, and by evaluating the available options and services.6 Their involvement helps patients and caregivers make the best choices to manage the complex world of healthcare. Cost is a major concern, but case managers should not focus solely on reducing costs. Instead, as these professionals advocate for the patient, they can help extend cost savings and other benefits to support systems such as insurance companies and hospitals.8
In 2009, the Healthcare Cost and Utilization Project estimated that 72% of patients discharged from hospitals were sent home without home health services. Additionally, discharges to home health services increased by 68% and discharges to long-term-care facilities increased by 34% between 1997 and 2009.9 As such, certified case managers must be knowledgeable about community resources, routinely reaching out to determine how these resources are changing.
According to CCMC statistics, certified case managers work in multiple settings, including insurance companies (28.8%), hospitals (22.8%), workers' compensation (11.6%), and independent organizations (7.3%) such as home health services or private insurers.10 As approximately two-thirds of these case managers work outside the hospital, they must remain experts in their local resources.
Although the CCMC data are unclear on the number of case managers working in patient homes, information is available to support in-home case management. For example, one literature review of community-based health programs demonstrated the efficacy of case manager home visits in decreasing healthcare utilization and improving quality of life in chronically ill older adults, as the following case study illustrates.11
JH, 82, has diabetes, chronic obstructive pulmonary disease, and coronary artery disease requiring multiple percutaneous coronary interventions. He also has age-related hearing loss. His daughter had recently moved in to take over as his primary caregiver, but she passed away suddenly. Within a week, JH was admitted to the hospital with unresolved chest pain. He was discharged to home clinically stable with no medication changes. Because he was not clinically homebound, he was not eligible for home health services. When he got home, he struggled to follow up with primary care appointments and care for himself due to grief.
His case manager, who worked for the hospital and had been making home visits for about a year before JH's daughter passed away, continued to assist him. The case manager scheduled a primary care appointment and called one of JH's friends to ensure he had the necessary transportation. During the follow-up appointment, JH's case manager was able to answer provider questions on his behalf, pick up any new prescriptions, and deliver them to JH's home.
Because JH's family did not live nearby, the case manager contacted them and recommended hiring private caregivers to help with meals, clean the house, and provide companionship during this difficult time. His case manager also continued to visit JH at home to assess his condition and alert other healthcare providers as needed.
Opportunity to serve
Not all patients require in-home case managers for success in healthcare management, but those who are older, chronically ill, or have little support may benefit from a visit. Case management is an exciting field and may offer a great opportunity for nurses to better serve their patients.
Case manager certification requirements12
Nurses and other members of the allied healthcare community can become case managers. To become certified, CCMC requires one of the following:
- a license or certification. Eligible healthcare professionals include RNs, certified rehabilitation counselors, certified disability management specialists, and licensed clinical social workers.
- a Baccalaureate or Master's degree in a health or human services field.
CCMC also requires experience as one of the following:
- 1 year as a case manager, supervised by a certified case manager.
- 2 years as a case manager, with certified case manager supervision not required.
- 1 year supervising case-management professionals.
Adapted with permission from: Commission for Case Manager Certification. CCM eligibility at a glance. 2019. https://ccmcertification.org/get-certified/certification/ccmr-eligibility-glance.
8. Harkey J, Young J, Carter JJ, Demoratz M. Supporting the support system: how assessment and communication can help patients and their support systems. Prof Case Manag
9. Healthcare Cost and Utilization Project. HCUP Facts and Figures: Statistics on Hospital-Based Care in the United States, 2009
. Rockville, MD: Agency for Healthcare Research and Quality; 2011.
11. Vandiver T, Anderson T, Boston B, Bowers C, Hall N. Community-based home health programs and chronic disease: synthesis of the literature. Prof Case Manag