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

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

doi: 10.1097/01.PCAMA.0000291423.76858.4f

Purpose of Study This is the third of a 3-part series presenting 2 effective applications—acuity and dosage—that describe how the business case for case management (CM) can be made. In Part I, dosage and acuity concepts were explained as client need-severity, CM intervention-intensity, and CM activity-dose prescribed by amount, frequency, duration, and breadth of activities. Concepts were presented that related the practice of CM to the use of evidence-based practice (EBP), knowledge, and methods and the development of instruments that measure and score pivotal CM actions. Part I also featured a specific exemplar, the CM Acuity Tool©, and described how to use acuity to identify and score the complexity of a CM case. Part II further explained dosage and 2 acuity instruments, the Acuity Tool and AccuDiff©. Part III presents linkage to EBP and practical applications.

Primary Practice Setting(s) The information contained in the 3-part series applies to all CM practice settings and contains ideas and recommendations useful to CM generalists, specialists, supervisors, and business and outcomes managers. The Acuity Tools Project was developed from frontline CM practice in one large, national telephonic CM company.

Methodology and Sample Dosage: A literature search failed to find research into dosage of a behavioral intervention. The Huber-Hall model was developed and tested in a longitudinal study of CM models in substance abuse treatment and reported in the literature.

Acuity: A structured literature search and needs assessment launched the development of the suite of acuity tools. A 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, b testing for content accuracy and appropriateness, and representative sample size testing were done. Expert panel reviews occurred at multiple junctures along the development pathway, including the 5 critical points after initial tool draft and both before and after b-test (n = 5) and pilot-test (n = 28) evaluations. 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–August 2000).

Results The Acuity Tools Suite was used to calculate individual case acuity, overall caseload acuity profiles, case length, and acuity differentials. Normal distributions and outliers were analyzed and the results were used for internal quality improvement and outcomes monitoring.

Implications for CM Practice To show value, case managers need to access the evidence base for practice, use tools to capture quantities of intervention intensity, and precisely specify the activities that produce better outcomes. Acuity and dosage can help case managers explore and fully describe their own practice in ways that can be measured, and thus provide data and evidence that contributes to the accumulating body of definitive proof regarding the exceptional worth of CM. Proving business and professional worth in CM through EBP is a clarion call that case managers must heed and an innovation that all case managers can practice.

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. She holds copyright to dosage concept and visuals.

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 President (Kingston), Canadian Hearing Society's Community Development Board member, and Cochrane Collaboration reviewer of evidence-based studies. She holds originator copyrights for CM Acuity Tool©, Caseload Matrix©, and AccuDif©.

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 this article was supported by grant DA08733, National Institute on Drug Abuse: 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 (phone: 319-335-4922; fax: 319-335-4662; e-mail:

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 Department, Two Liberty Plaza, Chestnut Street, Philadelphia, PA 19201. Contact Ms Craig via Craig Research Continuum, 313 Victoria St, Kingston, Ontario, Canada K7L 3Z2 (

The authors have no conflict of interest.

© 2007 Lippincott Williams & Wilkins, Inc.