History and Evolution of Case Management
Sandra Lowery
This chapter is a revised version of Chapter 1 in the first edition of CMSA Core Curriculum for Case Management. The contributor wishes to acknowledge Marlys A. Severson, as some of the timeless material was retained from the previous version.
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be able to:
Recognize the history of case management over the past century.
Discuss the impetus for its rapid growth over the past two decades.
Relate the professional development of case management practice.
List the purposes and goals of case management.
Understand the philosophical tenets of case management practice.
Define the domains of case management.
Describe case management, primary care case management, and care management.
Identify the national standards of practice and conduct for case managers.
IMPORTANT TERMS AND CONCEPTS
American Nurses Association (ANA)
American Nurses Credentialing Center (ANCC)
Association of Rehabilitation Nurses (ARN)
Care Management
Case Management
Certified Case Management (CCM)
Commission for Case Management Certification (CCMC)
Case Management Society of America (CMSA)
Domains of Case Management
National Association of Rehabilitation Professionals in the Private Sector (NARPPS, now IARP)
National Association of Social Workers (NASW)
National Council on Aging (NCOA)
Primary Care Case Management
Standards of Practice
▪ INTRODUCTION
A. Historical perspective
Early 1900s—Public health nurses and social workers coordinated services through the Department of Public Health.
1920s—Psychiatry and social work focused on long-term, chronic illnesses, managed in the outpatient community setting.
1930s—Public health visiting nurses used community-based case management approaches in their patient care.
1943—Liberty Mutual used in-house case management/rehabilitation as a cost-management measure for workers’ compensation insurance.
Post-World War II—Insurance companies employed nurses and social workers to assist with the coordination of care for soldiers returning from the war who suffered complex injuries requiring multidisciplinary intervention.
1966—Insurance Company of North America (INA, now CIGNA), led by George Welch, developed an in-house program that incorporated vocational rehabilitation and nurse case management, which later became known as Intracorp.
1970s—Due to the success of Liberty Mutual and INA in managing medical costs and returning workers to work, other workers’ compensation insurers developed case management programs.
1970s—Medicaid and Medicare demonstration projects employed social workers and human service workers to arrange for and coordinate medical and social services to defined patient populations in the community.
Spurred by the federally legislated deinstitutionalization of the mentally ill and mentally retarded population (now identified as the developmentally disabled)
National Long Term Care Channeling Demonstration Projects were funded by government community-based programs for the low-income and frail elderly, designed to maintain this population in the community.
1978—The Older Americans Act authorized case management for elders through area agencies on aging throughout the United States.
1980s—Health insurers developed case management programs, targeted at the catastrophically injured and ill population. Focus was on cost containment due to the double-digit inflation rate for medical costs.
Some programs were designed similarly to the workers’ compensation insurance models, with a focus on quality and cost of care to achieve results.
Some programs implemented a utilization management approach, with a focus on cost outcomes.
Late 1980s-2000—Provider-based programs proliferated in acute care hospitals; home care agencies, rehabilitation facilities, and skilled nursing facilities were established.
Often these case management models combined utilization review and discharge planning functions into a case management role.
Both nurses and social workers were hired for provider-based case management positions.
Growth of provider-based case management was spurred by the shifting of financial risk to provider organizations, as well as by external quality and cost demands by payers and accreditation bodies.
1990s-2006—Number of case managers increased to an estimate of greater than 100,000. Although cost containment remained important, the realization that quality care is an essential element to achieve this became a primary driver.
B. Impetus for the explosive growth of case management
Cost of health care—Increasing amount of the gross domestic product (GDP) goes toward health care, as compared with global competitors. In early 1990s, one-seventh of the United States GDP went toward payment for health care (Cohen, 1996). By 2004, this reached 15% and was still increasing (CMS).
Increasing consumerism secondary to more accessible information, increased expectations of patient involvement on the part of health plans, shift of health care financing to consumers, and negative repercussions of managed care
New emphasis on complementary and alternative medicine, with limited reimbursement by health plans
Information explosion through expansive use of electronic communication technology
Rapid development of genetic and medical advances
Growing emphasis on results, the value of health care dollars, and accountability for end outcomes
Significant changes in the health care delivery system and reimbursement for care
Increased fragmentation of care delivery
Increased level of consumer financial responsibility with decreased benefits, more co-pays and deductibles
Multiple levels and settings of care delivery, leading to much confusion, poorly coordinated care, poor care accountability, and cost shifting
Public awareness of the fallibility of the health care system
National reports such as “To Err is Human” and “Crossing the Quality Chasm” by the Institute of Health identifying safety problems from medical errors
Public report cards on providers, with comparative quality and cost data
Published data showing great variability in treatment, with inconsistent adherence to medical evidence, from the Dartmouth Atlas of Health Care and other national reports
Demands for quality care as well as cost effectiveness by private and public payers, through accreditation and pay-for-performance measures
Increased recognition of case management as beneficial for cost and quality outcomes
Demographics, including increased longevity, a growing aging population, geographic separation of extended families, and increased reliance on institutions for long-term care
C. Professional development and standards of practice became a necessity in order to set forth meaningful and relevant guidelines.
National standards for professional practice
Individual practitioner standards
Case Management Society of America (CMSA), 1995, revised 2002
National Association of Social Workers (NASW)
American Nurses Association (ANA)
National Association of Rehabilitation Professionals in the Private Sector (NARPPS)
National Council on Aging (NCOA)
Association of Rehabilitation Nurses (ARN)
National Association of Professional Geriatric Care Managers (NAPGCM)
Organizational standards
Utilization Review and Accreditation Commission (URAC), v. 1.0 through 2.0
Commission on Accreditation of Rehabilitation Facilities (CARF)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
National certification in case management
Certified Case Manager (CCM), CCMC, testing/credentialing began in 1993
Nurse Case Manager (RN, CM), ANA
American Nurses Credentialing Center (ANCC)
Certification in Continuity of Care, Advanced (A-CCC), American Association for Continuity of Care (AACC)
Certified Social Worker Case Manager (CSWCM), NASW
Certified Occupational Health Nurse Case Manager (COHN-CM), AOHN
Certified Rehabilitation Nurse, (CRRN), ARN
Certified Rehabilitation Counselor (CRC), Commission for Certified Rehabilitation Counselors
Care Manager, Certified (CMC), National Academy of Certified Case Managers
Commission for Case Management Certification (CCMC)
National journals and publications
Professional Case Management: The Leader in Evidence-Based Practice (Lippincott)
The Case Manager (Elsevier)
Care Management (Mason Medical)
Case Management Advisor (American Health Consultants)
Care Management Journals (Springer)
Education
Academic
Graduate degree programs in nursing case management
Certificate programs
Core curriculum for social work includes the core principles of case management
Continuing education
Online forums
Legislation affecting case management
Private sector
Workers’ compensation insurance
Laws for utilization review in some states
Varying laws in each state
Public sector
Medicaid waiver programs
Medicare waiver programs
Community human service agencies serving the mentally ill/developmentally disabled population
Professional associations
CMSA, international with local affiliates
NAPGCM, national with local affiliates
International Association of Rehabilitation Providers (IARP, formerly NARPPS), international with local affiliates
Association of Certified Case Managers (ACCM), national
American Case Management Association (ACMA), national with local affiliates
▪ KEY DEFINITIONS
A. ADL—Activities of daily living, which include activities carried out for personal hygiene and health.
B. Assessment—The process of collecting in-depth information about a person’s health and functioning to identify needs in order to develop a comprehensive case management plan that will address those needs. Information should be gathered from all relevant sources, as well as from client contact.
C. Autonomy—A form of personal liberty in which the client holds the right and freedom to make decisions regarding his or her own treatment and course of action, and to take control of his or her health, fostering independence and self-determination.
D. Case manager—A health care professional who is responsible for utilizing the case management process for individuals with health-related needs, with the goal of maximizing their wellness, autonomy, and appropriate use of resources.
E. Catastrophic case—Any medical condition that has heightened medical, social, and financial consequences.
F. Coordination—The process of organizing, securing, integrating, and modifying the resources necessary to accomplish the goals set forth in the case management plan.
G. Developmental disability—Any mental and/or physical disability that has an onset before age 22 and may continue indefinitely. It can limit major life activities.
H. Disability case management—A process of managing occupational and nonoccupational health conditions with the goal of returning a disabled employee to health, productivity, and employment.
I. Discharge planning—The process of assessing the individual’s care needs upon discharge from a health care facility or agency and ensuring that the necessary services are in place before discharge.
J. Implementation—The process of executing specific case management activities and/or interventions that will lead to accomplishing the goals identified in the case management plan.
K. Mental retardation—Subaverage general intellectual functioning manifested during the developmental period and existing concurrently with impairment in adaptive behavior.
L. Monitoring—The ongoing process of gathering sufficient information from all relevant sources regarding the effectiveness of the case management plan implemented.
M. Planning—The process of determining specific needs, goals, and actions designed to meet the client’s needs as identified through the assessment process.
N. Primary care—A process of assessing, planning, coordinating, and providing health care from a consistent practitioner who serves as the central point of contact for all other practitioners.
O. Provider—A person, facility, or agency that provides health care services.
P. Social work—A health care profession that promotes social change, problem solving in human relationships, and the empowerment and liberation of people to enhance well-being.
Q. Standards of practice—Statements of the acceptable level of performance or expectation for professional intervention or behavior associated with a professional practice.
R. Utilization review—A mechanism used by some insurers and employers to evaluate health care on the basis of medical appropriateness, necessity, and quality. Typically, it is used to determine access to an insurance benefit.
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