The Case Manager

Elizabeth Bodie Gross

Hussein A. Tahan

LEARNING OBJECTIVES

Upon completion of this chapter, the reader will be able to:

Differentiate between a role and function, and how they apply to the case manager.
Understand how the practice of the case manager has changed and expanded over time in the United States.
Identify how and why clients/patients have embraced and accepted case management services.
Understand why the case manager’s role continues to change and be dynamic in practice.
List the various functions case managers perform across the various venues of practice.

INTRODUCTION

A. Roles and functions of case managers are defined by professional organizations/societies (e.g., Case Management Society of America, American Nurses Association, and Commission for Case Manager Certification), based on scientific evidence, literature published by organizations that have implemented case management programs, and educational materials used in training and education of case managers.

B. Roles and functions of case managers are usually written in an organization in the form of job descriptions. However, the research literature that addresses what case managers do tends to report a taxonomy (or a list) of activities and tasks of case management based on which job descriptions can be delineated.

C. The role of the case manager has been implemented in every setting of the health care continuum (pre-acute, acute, post-acute, and rehabilitative) and is assumed by a variety of professionals such as nurses, social workers, rehabilitation counselors, disability specialists, workers’ compensation specialists, and others.

D. There is no standard job description for case managers. However, the literature shares common or core aspects of case management practice: clinical/patient care, managerial/leadership, financial/business, and information management.

KEY DEFINITIONS

A. According to the Merriam-Webster Dictionary (2000), key case manager role-related terms are defined as follows:

Domain—A sphere of knowledge, influence, or activity. In case management, it refers to an area or category of practice and/or knowledge.
Function—Any of a group of related actions contributing to a larger action. In case management, it is the activities a case manager performs in his or her job.
Role—A function or part performed especially in a particular operation or process; the proper function of a person or thing. In case management, it refers to the case manager’s job title or position.
Venue—The scene or locale of any action or event. In case management, it refers to the type of agency/organization a case manager works in and what population he or she serves.

B. Tahan, Huber, and Downey (2006) defined the terms activity, function, and role as described below and used these conceptualizations to guide their research on roles and functions of case managers.

Activity—A discrete action, task, or behavior performed by the person in the role to meet the goals of the role; for example, “list the medications a patient takes while at home.”
Function—A grouping or composite of specific activities within the role. These activities are interrelated and share a common goal; for example “coordination of care activities.”
Role—A general and abstract term that refers to a set of behaviors and expected results that is associated with one’s position in a social structure. A proxy usually used for the role is the individual’s title; for example, the “case manager.”

C. Other case management-related terms are as follows:

Case manager—A health care professional who works with the patient and family as well as the health care team in the coordination of care activities and treatment or plan of care. He or she may be engaged in many activities such as patient and family education, counseling, outcomes monitoring, utilization management, and others. The case manager may be a registered nurse, a social worker, a physical therapist, a vocational rehabilitation counselor, or some other licensed health care professional.
Context—The environment or work structure in which a case manager functions; for example, managed care organization or payerbased case manager, hospital or acute care.
Job description—A document that describes roles and responsibilities, which when executed produces intended results. It also describes general tasks, responsibilities, and functions; identifies the individual/position to whom the case manager reports; and specifies the required qualifications for the job such as educational background, years of experience, and certification.

BACKGROUND

A. Over the past 25 years, the field of case management has evolved to meet the changing nature of the health, social, and medical care systems. Although the process of case management remains the same, the roles, functions, and venues continue to change and evolve.

The process of case management (discussed in Chapter 9) permeates every aspect of the health and medical care systems, and now this process is beginning to be used in other industries as well (e.g., legal and business).
This chapter focuses on how the roles and functions of a case manager are executed via the case management process.

B. Chapter 1 provides a great summary of the practice of case management over the past 100 years.

C. In 1982, when the U.S. Congress passed the Tax Equity and Fiscal Responsibility Act (TEFRA), it pushed third-party payers to integrate case management services across all lines of health, social, financial, and medical services to control costs and manage limited resources.

D. The case management community established several professional case management associations and organizations that were focused on advancing the practice of case management and its value in the United States. For example,

Case Management Society of America (CSMA)—established in 1990
National Association of Professional Geriatric Care Managers (NAPGCM)—established in 1985
Commission for Case Manager Certification (CCMC)—established in 1992

E. In the 1980s, the difference between case and care management was established.

Case management is a term used to refer to the management of acute and rehabilitative health care services. Services are delivered under a medical model, primarily by nurses.
Care management is a term used to refer to the management of long-term health care, legal, and financial services by professionals serving social welfare, aging, and nonprofit care delivery systems. Services are delivered under a psychosocial model.
In the mid-1980s, case and care management entrepreneurs emerged and started independent, for-profit companies or private practices that focused on selling case management services as a niche product for the care of a specific population (e.g., the disabled, the workrelated severely injured, and most recently the chronically ill).

F. By the 1990s, other health care-related professionals (e.g., physical, occupational, and speech therapists; gerontologists; etc.) began to offer case and care management services on a fee-for-service basis in different practice venues.

G. In 1997, the Foundation for Rehabilitation Education Research (FRER) and NAPGCM co-sponsored a case/care management summit to discuss the future of case and care management in the United States.

The summit was held in Chicago in October, 1997. Sixteen (16) professional associations/organizations attended to discuss their vested interest in case/care management and its future in the United States. Participants included the following:
- American Association of Occupational Health Nurses
- American Nurses Credentialing Center
- American Society on Aging
- Case Management Society of America
- Certification of Disability Management Specialist Commission
- Commission for Case Manager Certification
- Commission on Rehabilitation Counselor Certification
- Foundation for Rehabilitation Education and Research
- Health Insurance Association of America
- Institute of Case Management
- National Academy of Certified Care Managers
- National Association of Case Management
- National Association of Professional Geriatric Care Managers
- National Association of Social Workers
- National Guardianship Association
- National Guardianship Foundation
The goal of the 1997 Case and Care Management Summit was to: “foster cost-efficient, collaborative professional interactions that effectively integrate the medical, psychological, and social elements of each client/provider relationship in a manner that includes the essential activities of case management in order to provide timely, appropriate and beneficial service delivery to the client. These activities include, but are not limited to, assessment, planning, coordination, implementation, monitoring, education, evaluation, and advocacy. Such integration would encompass, but not be limited to, clients and their families, health care providers, community agencies, legal and financial resources, third-party payers and employers” (Gross and Holt, 1998, p. 4).
The 1998 summit also recommended that a second summit be organized to:
- Examine and establish minimum standards for qualified case management practitioners and how case managers demonstrate ongoing competency (includes reviewing the different levels of education required for existing credentials and determining the need to standardize the entry level criteria)
- Document successful case management outcomes in order to demonstrate the value of the case manager credential
- Develop educational materials to answer basic questions and inform consumers about the qualifications of various providers, as well as the types of services care and case managers offer their clients.
- Use market research to identify the information needs of specific stakeholders.
- Review organizational codes of ethics in order to establish a common code of conduct that all care and case managers could endorse (in addition to their existing codes). Overall code would include, at a minimum, individual scope of practice, requirements for professional disclosure, clarity on conflicts in interests, cultural competency of practitioners, and client confidentiality.
- Identify minimum requirements for a qualified practice, develop a mechanism to standardize existing credentials, conduct periodic review of professional development criteria, and determine the need for advanced credentials for care and case managers
The Second Case and Care Management Summit (1999) was held in Chicago to discuss the topics outlined in the 1998 Summit I Discussion Paper. Participants remained the same, except that the Institute on Case Management did not attend. At the conclusion of this summit, the Coalition for Consumer-Centered Care and Case Management was established. The Coalition was dissolved in 2001 due to a lack of funding.

H. In 1999, Michaels and Cohen (Cohen and Cesta, 2005) redefined care and case management as follows:

Care management establishes a system of care for a particular condition, across the continuum of care to ensure seamless transition to the right services, right providers, and at the right time and encourages patients and their family/caregiver to manage their own health. Such care is facilitated by a case manager.
Case management is a way of managing unique and high-risk situations often associated with costly acute care and hospital stay. Typically, those who require case management are individuals whose self-care capacity is diminished at a time when their health condition is most complex or even life threatening. Such care is facilitated by a case manager.

CASE MANAGEMENT ROLES

A. Since the 1980s, the case manager’s role has evolved, transforming itself from being an evaluator of health care services to a procurer and negotiator of health, medical, social, legal, and financial services. The role of a case manager has become more sophisticated and active in the care of an individual. Case managers are required to professionally and legally provide state-of-the-art and ethical services.

B. The changes that have catapulted case managers into the forefront of the health and medical care delivery systems include the following:

Increased complexity of coordinating and financing health/medical care services
More than 50 million Americans do not have medical/health insurance and need a case manager to help them navigate and procure needed health/medical care services with limited financial resources.
Due to the economy, many health, medical, and social care agencies and institutions are reducing their list of services because they are deemed to be unprofitable or a “losing asset.”
Many social service agencies have reduced or eliminated services and subsidies (e.g., sliding scales) due to a lack of government funding and grants.
Nonprofit and federally/state-funded social service agencies and organizations are closing down due to a lack of overall funding. This situation is referred to as the “dissolution of the U.S. social service infrastructure.”

C. Most important case management roles as identified by Tahan (2005) include the following:

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