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Acuity and Case Management: A Healthy Dose of Outcomes, Part I

Huber, Diane L. PhD, RN, FAAN, CNAA, BC; Craig, Kathy MS, RN, CCM

doi: 10.1097/01.PCAMA.0000271363.55428.2d

Purpose of Study This article presents acuity and dosage as two concepts that describe how the business case for case management (CM) can be made. Dosage and acuity concepts are explained as client need-severity, CM intervention-intensity, and CM activity-dose by amount, duration, extent, and timing. Concepts are related to the practice of CM using evidence-based knowledge and methods to develop instruments that measure and score pivotal CM actions. The purpose of this series of three articles is to introduce the two concepts of dosage and acuity, discuss their importance for making the business case for CM and for translation into evidence-based practice, and present a powerful example of how they can be used in everyday CM. The articles feature a specific exemplar, the CM Acuity Tools project, and explain how the melding of the acuity and dosage innovations will improve the capture of CM outcomes. Part I focuses on the CM Acuity Tool© instrument.

Primary Practice Setting(s) The article's information applies to all CM practice settings, and contains ideas and recommendations useful to CM generalists, specialists, supervisors, and outcomes managers. The Acuity Tools Project was developed from frontline CM practice in one large, national telephonic CM company.

Methodology and Sample For dosage, the Huber-Hall Dosage Model and its testing are described and explained. The intersection of dosage and acuity is analyzed. For the Acuity Tools Project, a structured literature search and needs assessment launched the development of the suite of acuity tools. The resulting gap analysis identified that an instrument to assign and measure case acuity specific to CM activities was needed. Clinical experts, quality specialists, and business analysts (n = 7) monitored the development and testing of the tools, acuity concepts, scores, differentials, and their operating principles, and evaluated the validity of the acuity tools' content related to CM activities. During the pilot phase of development, interrater reliability testing of draft and final tools for evaluator concordance, beta (β) testing for content accuracy and appropriateness, and representative sample size testing were done. Expert panel reviews occurred at several junctures along the development pathway, including after initial tool draft and both before and after β-tests (n = 5) and pilot tests (n = 28). The pilot testing body (n = 33) consisted of a team of case managers (n = 28) along with quality analysts (n = 2), supervisory personnel (n = 2), and the lead product analyst (the developer). Product evaluation included monitoring weekly reports of open cases for the 28 case managers for 3 months (June to August 2000).

Results Positive results generated approval from the expert review panel to apply the suite of acuity tools beyond (1) the initial draft phase, (2) the test population phase, and then (3) at a national CM organization level.

Implications for Case Management Practice This article defines and discusses acuity and dosage as two practical conceptual tools that successfully unite clinical quality and business practices and measure and analyze CM activities. The CM Acuity Tool© is a master conceptual framework in three dimensions that synthesizes key components of CM practice, organized into indicators, drivers, and subdrivers. To show value, case managers need to access the evidence base for practice, use tools to capture quantities of intervention-intensity, and specify the activities that produce better outcomes.

Diane L. Huber, PhD, RN, FAAN, CNAA, BC, is Professor, Colleges of Nursing and Public Health, University of Iowa, Iowa City, teaching and doing research in case management and nursing administration. She is the author/editor of Leadership and Nursing Care Management and Disease Management: A Guide for Case Managers.

Kathy Craig, MS, RN, CCM, CRA, practices case management in 1000 Islands area, Ontario, Canada, and runs Craig Research Continuum for personal health research, biomedical writing, and innovative tool development. She serves as Business and Professional Women Canada vice president (Kingston), Canadian Hearing Society's Community Development Board member, and Cochrane Collaboration reviewer of evidence-based studies. She holds the originator copyrights for CM Acuity Tool©, Caseload Matrix©, and AccuDiff©.

Address correspondence to Diane L. Huber, PhD, RN, FAAN, CNAA, BC, College of Nursing, University of Iowa, Iowa City, IA 52242 (

The dosage research discussed in these articles was supported by Grant #DA08733, National Institute on Drug Abuse (NIDA): Iowa Case Management Project for Rural Drug Abuse, PI = James A. Hall, PhD, LISW, Center for Addictions Research, M304 Oakdale Hall, University of Iowa, Iowa City, IA 52242 ( The Acuity Tools Project occurred at Intracorp's Center for Clinical Outcomes and Guidelines (1999–2000). CIGNA/Intracorp holds corporate copyrights and Kathy Craig, MS, RN, holds originator copyrights for Case Management Acuity Tool©, Caseload Matrix©, and AccuDiff©. Send inquires to CIGNA PR Dept., Two Liberty Plaza, Chestnut Street, Philadelphia, PA 19201. Contact Craig via Craig Research Continuum, 313 Victoria St., Kingston, Ontario, Canada K7L 3Z2 (

© 2007 Lippincott Williams & Wilkins, Inc.