The Case Management Society of America (CMSA) has been an organizing force setting the practice direction for the discipline of case management, through its representation, advocacy, and education functions. The CMSA promotes practice that is evidence based and discourages the use of practices which, though popular or widely accepted, are either not beneficial or are contrary to the standards of practice (SOP). Although the increasing emphasis on care coordination by providers and payers has opened professional debate regarding the models being used in hospitals today, the CMSA intends to clarify its position on hospital case management practice through a forthcoming white paper and urges hospital leaders to seek solutions that more effectively address the needs of our most vulnerable hospitalized patients.
It is no secret that the hospital industry is in the midst of seismic changes. From the scale of mergers and acquisitions among hospital and nonhospital entities to the expansion of convenient ambulatory services centers, health care systems are under overwhelming pressure to improve patient outcomes and lower costs. Value-based inducements were introduced to incentivize hospital leaders to improve delivery of care processes and promote collaborative, interdisciplinary interactions. The traditional private medical practice is waning, because medical practices are consolidating and medical homes are created. All these changes are taking place at the speed of light.
To adapt and survive in this new marketplace, hospital leaders are scrambling to take advantage of every bit of institutional talent to make changes that reflect the new reality. As a result, hospital case management, in general, and care coordination specifically have suddenly caught the attention of hospital executives.
According to the Agency for Healthcare Research and Quality (AHRQ), the main goal of care coordination is to meet patients' needs and preferences in the delivery of high-quality, high-value health care. Care coordination is not a synonym for transition planning but a process that “ensures that the patients' healthcare needs and preferences are known and communicated at the right time, to the right people, and that this information is used to guide the delivery of safe, appropriate and effective care” (AHRQ, 2014). Any activity that bridges gaps between providers, care teams, settings, and provides information important to the treatment plan, and patient flow, leads to improved care coordination. Furthermore, case management is designed to “assist patients and their support system in managing their medical, social, and mental health conditions more efficiently and effectively” (AHRQ, 2014). In a 1998 study, case management was defined as a “means of coordinating services” by a single case manager who is expected to assess that person's needs, develop a care plan, arrange for suitable care to be provided, monitor the quality of the care provided, and maintain contact with the person (Marshall, Gray, Lockwood, & Green, 2000). Recognition of the confirmed connection between case management and care coordination energized the taskforce in its mission.
The CMSA established the SOP for case management in 1995 and has revisited and updated the content four times to reflect the changing health care system and the changing role of the case manager. The most recent change in the SOP was made in 2016. The CMSA emphasized the professional role of the case manager and the need to empower patients and their caregivers in important decisions regarding their care, to promote health care literacy and self-care, and to engage the patients' participation and their transitions from the hospital (CMSA, 2016). Key provisions in the SOP include:
- Identify and select patients who can most benefit from case management services.
- Complete health, cognitive, and social assessment.
- Identify problems or opportunities that would benefit from case management interventions.
- Collaborate with the client and stakeholders to develop an individualized plan.
- Facilitate, coordinate, monitor, and advocate to “minimize fragmentation in the services provided and prevent the risk for unsafe care and suboptimal outcomes.”
- Employ ongoing monitoring to measure the client's responses.
- Demonstrate the benefits of case management services (CMSA, 2016).
Using these standards, the taskforce endeavored to identify what, if any, constraints exist in the hospital environment that impede the application of these practice principles. The taskforce then identified strategies that can be used to ensure that hospital case management practice models are in synch with the transformation taking place throughout the hospital industry.
The taskforce identified the following transformation priorities for hospital case manager leaders and the hospitals' senior administrative team:
1. Redesign scope of services. For many years, hospital case management was a hospital department charged with managing several hospital functions. But that model no longer meets the challenges of the modern acute care delivery system, population health initiatives, nor the establishment of community-based partnerships that many acute care hospitals find essential to thrive in a value-based environment. New consumer expectations, new payment schemes, and new alliances demand a case management model that focuses on an enterprise-wide program of care coordination.
Care coordination is an essential component of the SOP promulgated by the CMSA (2016), and is also cited by the National Quality Forum (2010), the National Healthcare Quality and Disparities Report chart book (AHRQ, 2016), and the Institute for Healthcare Improvement (Craig, Eby, & Whittington, 2011) as an essential service delivery plan (Bodenheimer, 2008). Care coordination is at the heart of any new hospital case management model and leaps the brick and mortar boundaries of the acute care facility into other care facilities, community-based settings, and the patient's home. This much broader vision can pose significant challenges when planning for the future. Not only does the hospital system require strength and cohesiveness within the walls of the facility, but also within the larger web of the surrounding community's infrastructure and support systems. Care coordination can no longer exist and function within a solitary hospital department located in the bowels of the facility; it must become a core competency of every hospital organization and evolve into a program where every hospital caregiver provides value that results in better outcomes at lower costs.
2. Establish clear roles and responsibilities. The 2010 Affordable Care Act has put a focus on the improvement of health outcomes, specifically calling out effective case management and care coordination as activities to achieve these outcomes. By moving the case manager's focus away from tasks and procedures as the focus of their scope of practice sharpens, opportunities will be created to meet the needs of the health care consumer and add to the value of case managers (Lucotorto, Thomas, & Siek, 2016).
Case management practice extends beyond the basic training of any single discipline within the health care field. Organizing for patient-centric care coordination suggests a program composed of diverse individuals with the skill sets, critical thinking skills, and enthusiasm to coordinate care for a selected group of patients in the hospital and across the continuum. Eligible individuals may come from many professional clinical disciplines and have strong communication and collaborative skills to engage the patient and members of the patient's care team.
Mary McLaughlin-Davis, DNP, ACNS-BC, NEA-BC, CCM
Agency for Healthcare Research and Quality. (2016). National Healthcare Quality and Disparities Report chartbook on care coordination. Rockville, MD: Author.
Bodenheimer T. (2008). Coordinating care–a perilous journey though the health care system. The New England Journal of Medicine, 358(10), 1064–1071.
Case Management Society of America. (2016). Standards of practice for case management. Little Rock, AR: Author.
Craig C., Eby D., Whittington J. (2011). Care coordination model: better care at lower cost for people with multiple health and social needs. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement.
Lucotorto M. A., Thomas T. W., Siek T. (2016). Registered nurses as caregivers: Influencing the system as patient advocates. Online Journal of Issues in Nursing, 21(3), 10913734.
Marshall M., Gray A., Lockwood A., Green R. (2000). Case management for people with severe mental disorders. The Cochrane Database of Systematic Reviews. (2), CD000050.