REACTION PAPER

CASE MANAGEMENT: KEY TO ACCESS, QUALITY, AND FINANCIAL SUCCESS

Case management is not a new concept. it traces its history when it simply functioned as
a means of providing care and containing healthcare costs. The practice found its roots in the
fields of psychiatry and social work, and focused on long-term chronic illness that were managed
within the community. Case management processes were also used by visiting and public health
nurses when making house calls was a common practice. Throughout the next 50 years, case
management remained essentially in the community. Case managers are found across the
continuum of care and serve as advocates for patients and their families navigating the complex
healthcare system. their multifaceted roles ensure that patients receive high-quality care in the
least restrictive settings for the most cost-effective price in an organized and coordinated manner.
Today, case managers are the vital link in a complex healthcare system that is often unfamiliar
and confusing.
The practice of case management is designed to formulate a plan that enables the patient
to move smoothly through the healthcare system. to achieve this, case managers work closely
with many stakeholders: patient, their family members, their caregivers, the healthcare team,
payers and communities.
Case management is not a profession unto itself but a practice that encompasses many
disciplines. Nursing is the predominant field of the practice of case management, while social
workers and other healthcare professionals combine to make up a mix of dynamic professionals
with a central goal to focus the system and facilitate the delivery of care. The discipline of
nursing focuses on the whole person, which is a key case management concept. the broad
training and skills that nurses acquire allow them to assess patients care. It is important to
remember that no single discipline owns the practice of case management. Therefore, it is
essential that each individual involved in the practice of case management.
Case management is a collaborative process of assessment, planning, facilitation, care
coordination, evaluation and advocacy for options and services to meet an individuals and
familys comprehensive health needs through communication and available resources to promote
quality cost-effective outcomes.
 The philosophy of case management is that all individuals are eligible for case
management services regardless of age, culture, or ability to pay for service. Yet, it is important
to realize that not everyone requires case management.
This ratio reveals the population most appropriate for case management services. For
case management to succeed, early risk identification, using proven indicators, and the
stratification of the group according to these indicators is critical so that appropriate
interventions and resources are utilized.
Case management is a voluntary service, so gaining permission from, and establishing
trust with the patient, family and caregivers is critical. To achieve positive outcomes, the
cooperation of the patient, family and caregiver is needed to ensure adherence with the plan of
care.
Each profession establishes its own standard of practice. Members of these professions
the professionals are assumed to have extensive theoretical knowledge and possess skills based
on knowledge that they are able to apply in practice. Members of professions organize
professional bodies, which are intended to enhance the status of their membership and have
carefully controlled entrance requirements. Professions have extensive periods of education and
testing for competence. Before being admitted to membership of a professional body, there is
usually a requirement to pass prescribed examinations based on theoretical knowledge. In
addition to examinations, there is usually a requirement for periods of institutionalized training
where aspiring professionals acquire specified practical experience in a trainee role before being
recognized as a full member of the professional body. Mandatory continuing education, through
professional development, updates the professionals skills and knowledge. Licensed
practitioners have a code of professional conduct, or ethics and disciplinary actions are taken for
those who infringe upon the code.
Professions are self-regulating and independent from government. They tend to be
policed and regulated by senior, respected practitioners and the most highly qualified members
of the profession. Professionals are autonomous and mobile; standardization of professional
training and procedures enhances this mobility. In addition, professionals have a commitment to
public service and altruism.
When the practice of case management was becoming widespread in various settings
throughout the care continuum, there were no standards of practice, no certifications, and no
formal policies explaining what case management was. Nurses, social workers and vocational
specialists who made up the practice used their professional skills and intuition to find their way
instead.
Those early pioneers said that case management was accomplished by treating patients in
the same ways they would want their families to be treated. The competencies of this Golden
Rule that is, do unto others, included clinical experience, compassion, empathy, personal
relationship skills, and common sense. The goal was then as it is now to ensure that patients
received safe care, at the right time, in the right place, and for the most cost-effective price.
One of the case managers key roles is advocating for and negotiating on behalf of the
individuals so that they have access to the services and equipment identified in their care plan.
The case manager can also negotiate directly with service providers where patients and carers
cannot do this for themselves. As a result, the case manager may be able to negotiate a prompt
response to referrals or speed up the process of obtaining medication, equipment or home care
services. Case managers often advocate on behalf of patients when they are discharged from the
hospital and support individuals to make care choices.
Case management leaders began to explore how one could validate ones expertise. By
networking with the organization that provided certifications in the areas of disability
management and vocational care, the group set up the first certification for case managers and
developed both the exam and the established criteria by which professionals would be measured
in order to determine whether they were qualified to sit for examination.
Case management is a multidisciplinary practice, yet majority of practicing case
managers are nurses. The initial training of those new to the practice includes the history of the
practice, introduction to the case management Standards of Practice, and an overview of the job
description and training in the organizations policies and procedures. Case management is a
system of patient care delivery that focuses on the achievement of outcomes within effective and
appropriate time frames and resources. It focuses on an entire episode of illness, crossing all
settings in which the patient receives care. Care is directed by a case manager who ideally is
involved in a group practice. He/she is responsible the nursing diagnosis, develops the nursing
care plan, delegates nursing care to associates, activates interventions, coordinates and
collaborates with interdisciplinary team and evaluates outcomes of care. In institutions these
activities are done prior to admission and continue to about two to three weeks after discharge. In
communities, activities occur in any setting the home, clinic or hospital as long as necessary.
The best known examples are prepaid health care plans and health maintenance. To be positive,
relationships must be nurtured between the case manager and physicians, primary nurses, public
health nurses and interdisciplinary staff.
The core components of the practice of case management are the same across all settings.
Yet each of setting has its own rules and regulatory issues that case managers must be aware of
and follow. For example, case managers who practice in the hospital setting come in contact with
a variety of payers policies, regulations and legislation to which they must adhere. Those who
work in managed care organizations must be aware of the various benefits plans offered and the
regulations that accompany these plans in the states where they are offered. Those in workers
compensation must follow the specific laws and regulations set forth by each state. To ensure
case management professionals understand the nuances of their practice, organization policies
and procedures and are trained and informed, preceptorship and mentoring programs are an
integral part of most orientation programs.
Mentoring and preceptorship programs are two of the more commonly used role-
modelling programs designed to sustain the learning and professional growth of nurses and to
promote the overall quality of the practice settings. Many aspects of mentoring and preceptorship
are similar. Both approaches depend upon effective one-on-one role-modelling; self-directed
learning; a safe environment for reflection and practice; and the acts of advising, counseling,
guiding, advocating, recognizing strengths and providing constructive feedback.
Preceptorships offer staff development training, technical assistance, and quality control
through the development of an individualized tutorial relationship with each case manager. It is a
unique program of professional growth and development designed for each case manager. It is a
unique program of professional growth and development designed for each case manager being
supervised. Preceptors are generally experienced case managers who provide support and
guidance to new members of the team. Preceptors work closely with students on an ongoing
basis to plan the orientation and to review clinical practice and learning experiences that may
arise. This enhances the preceptees awareness of various scenarios while the preceptor monitors
the preceptees progress and provides feedback on performance in order to help with the
transition and integration into the organization. Preceptorships tends to focus on a formal process
for helping the new professional acquire beginning-practice competencies through direct
supervision over a limited period of time.