It used to be that hospital case management (HCM) could succeed simply by providing solid utilization review and discharge planning activities. But as expectations for higher levels of service intensify and demands for value accelerate, those days have drawn to a close. Today, cutting-edge programs are identifying ways to meet or exceed the expectations of the baby boomers through assertive advocacy and a strong focus on access, cost, and outcomes (Wolfe, 2006).

A. According to industry observers, hospitals will succeed by establishing partnerships with their stakeholders and developing solutions that are tailored to their unique needs.

B. Case manager partnerships with physicians is a popular strategy to help the medical staff work through a morass of industry challenges that can, at times, be complex, frustrating, and intimidating.

C. Hospital case management continues on its evolutionary track and there is no single model of hospital case management, nor is there “one best way.”

D. From the perspective of many progressive hospital executives, HCM should now achieve three major outcomes:

E. The new generation of HCM programs are typically structured and operationalized to rapidly achieve these three goals. Within these programs, there are many features that should be integrated into every hospital’s program no matter where they are on the evolutionary scale (Daniels and Ramey, 2005).

A. Advocacy—A process that promotes beneficence, justice, and autonomy for clients. Advocacy especially aims to foster the client’s independence. It also involves educating clients about their rights, health care and human services, resources, and benefits. Advocacy facilitates appropriate and informed decision making, and includes considerations for the client’s values, beliefs, and interests (Gilpin, 2005).

B. Congruency—The “fit” between HCM and its environment.

C. Continuity—In practical terms, continuity means that a single case manager will consistently serve as the patient’s advocate, quality inspector, and information source in every geographic area in which the patient is placed.

D. Infrastructure—Relates to the alignment of HCM within the organizational structure; the nature of the team and the positions within the HCM program; and the assignment, staffing, and scheduling of case management team positions.

E. Resource management—Encompasses a diverse set of activities designed to influence the efficient and appropriate use of hospital resources; may be tangible or intangible; is a balance of patient advocacy and the organization’s obligation to appropriately allocate resources; and is a prospective process to monitor the appropriate use of resources for the condition and to offer acceptable alternatives.

F. Visioning—A collective process of imagining the future.

A. Hospital case management has its roots in the expanded role of the clinical nurse at Massachusetts’ New England Medical Center (Zander, 1988). It was originally conceived as a cost-containment strategy to help hospitals deal with the nursing shortage and the world of managed care, but has expanded as a means to decrease resource consumption, reduce costs, and improve the continuity and quality of patient care (Stonestreet, 1999).

B. Over the years, the influence of the New England Medical Center clinical model has led to a variety of similarly conceived programs, although no single model has surfaced.

C. As the U.S. hospital industry undergoes dramatic changes in the structure and processes of care delivery, the case manager has emerged as an important part of the workforce and a key driver of managing access to care, coordination of care, and cost/quality outcomes.

The primary purposes of case management—to advocate on behalf of the patient, facilitate the delivery of quality and appropriate care in a cost-effective manner, while seeking to promote positive health care outcomes—remain constant regardless of the practice venue. However, the practice of case management in a hospital looks quite different from case management practiced in a community health program or an insurance company.

A. There are three key dimensions that distinguish case management in the hospital from those in other practice venues.

Hospital case management operates within a supply-driven market. It is often the provider (the physician) rather than the consumer (the patient) who determines the type and extent of treatment, care, or services required. To a modest degree, the explosion of the baby-boomers, news media, the Internet, and direct-to-consumer advertising have eroded a portion of this market. Nevertheless, within the acute care environment, it is safe to say that, for the most part, the physicians’ practice choices drive resource consumption, costs, and outcomes.

A. To influence the type and extent of practice choices and promote appropriate and cost-effective interventions, a collaborative partnership between the case manager and the physician must be nurtured and centered on the consumer (patient).

B. Case manager-physician partnerships are not forged overnight and often said partnership may be perceived as an infringement on partner prerogatives. Careful thought must be given to strategies meant to overcome the perceived static nature of the medical role.

C. While many HCMs might describe their relationship with the physicians as a “partnership,” in reality, each provider works independently toward acommon goal. An authentic collaborative partnership exists when the physician and the case manager work in tandem to achieve the desired goal.

D. Working in tandem may mean adopting new styles of communication or anew attitude. It means that the case manager will probably be: making rounds with the physician partner whenever feasible; questioning practice decisions and offering alternatives; and deciding together whether a patient’s immediate needs require an acute care admission or whether the patients’ continuing needs require an acute level of care. Optimal patient advocacy requires continual diligence to minimize the patient’s exposure to unnecessary risk. Successful case managers work with the physician not around him/her.

E. Despite the case manager’s level of clinical competence, the case manager’s role is not to exercise clinical skills, but rather to apply critical thinking skills, knowledge of health care treatments, familiarity with evidence-based interventions, and erudition of the health care system to influence the physician’s medical decision making. To promote a safe, cost-effective episode of acute care, working in tandem with the physician is key (Daniels and Ramey, 2005).

F. To influence a physician so that treatment decisions are made timely, appropriately, and in the patient’s best interest, a conceptual shift to problem solving from the customer’s perspective must occur and become second nature to the hospital case manager. If the case manager can recognize what is important to the physician, that insight can be used to offer a trade, or exchange, that brings value to the physician in practical terms.

G. Physicians want help in effectively managing their time while in the hospital. They are interested in having:

H. Physicians are generally driven by professional commitment and a personal set of values. However, few are willing to commit to dramatic alterations in their practice, their routine, or their time unless it has personal value.

I. Physicians are typically driven by their own financial self-interest and will engage in a partnership with the case manager when they see that the exchange makes economic sense and brings value to him or her on a professional level (“The Performance Equation,” 2003).

J. By and large, physicians will not buy into a case management program and acceptance will never occur if the physician perceives the role of the case manager as being simply to police his/her patients’ charts, reduce length of stay, cut costs for the hospital, or challenge his/her medical judgment.

As programs continued to evolve, no single “reference model” of acute care case management has emerged. As a result, HCM today is often a reactive conglomeration of activities without a coherent vision or rational intent.

A. Envisioning the future—Given the chaos in the current hospital environment, coupled with the lack of a reference model for HCM, every successful program first creates a vision for the model.

B. While determining the purpose and intent of the hospital’s case management program, important and sensitive outcomes are articulated.
Knowledge at the outset on how HCM will be evaluated gives planners information to help design a relevant infrastructure and operations.

C. There are two overarching case management goals in the acute care setting.

How each of these goals is translated into measurable objectives is a product of data accessibility, priorities, and manpower. With a clear understanding of the program’s vision, purpose, goals, and objectives, a series of positive concepts or principles can be developed to serve as the framework for a model of HCM.

D. Some of the frequently encountered principles found in successful care delivery programs include activities related to the following domains:

E. Some elements of the original clinical New England model still exist. Clinical case management models or collaborative practice models are typically seen in larger, urban teaching centers. Although pure clinical care/case management models are rare, the collaborative model—known more popularly as a dyad or triad model—is frequently found in large, tertiary facilities where the high costs of these models can more easily be absorbed. The collaborative model typically features a team made up of a case manager, a utilization review specialist, and a social worker.

F. However, community hospitals overwhelmingly use a functional model created by either consolidating or integrating utilization review and discharge planning activities.

G. Clinical resource management (CRM) models represent the next generation of case management programs in hospitals.