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Case Management in Health Care
The Case Management Society of America defines case management as:
- "a collaborative process of assessment, care planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes."
Case management focuses on delivering personalized services to patients to improve their care, and involves four steps:
- 1) Screening to find appropriate patients
- 2) Planning & delivery of care
- 3) Evaluation of results for each patient & adjustment of the care plan
- 4) Evaluation of overall program effectiveness & adjustment of the program
In the context of a health insurer or health plan it is defined as:
A method of managing the provision of health care to members with high-cost medical conditions. The goal is to coordinate the care so as to both improve continuity and quality of care and lower costs.
Case managers working for health insurers and HMOs typically do the following:
- 1) Check benefits available;
- 2) Negotiate rates with providers who are not part of the plan's network;
- 3) Recommend coverage exceptions where appropriate;
- 4) Coordinate referrals to specialists;
- 5) Arrange for special services;
- 6) Coordinate insured services with any available community services; and
- 7) Coordinate claims with other benefit plans. 
By identifying patients with potentially catastrophic illnesses, contacting them and actively coordinating their care, plans can reduce expenses and improve the medical care they receive. Examples include identifying high-risk pregnancies in order to ensure appropriate pre-natal care and watching for dialysis claims to identify patients are risk of end-stage renal disease. The amount of involvement an insurer can have in managing high cost cases depends on the structure of the benefit plan. In a tightly managed plan case management may be integral to the benefits program. In less tightly managed plan, participation in a case management program is often voluntary for patients.
Case managers working for health care providers typically do the following:
- 1) Verify coverage & benefits with the health insurers to ensure the provider is appropriately paid;
- 2) Coordinate the services associated with discharge or return home;
- 3) Provide patient education;
- 4) Provide post-care follow-up; and
- 5) Coordinate services with other health care providers. 
- Case mix
- Case report
- Case presentation
- Discharge planning
- Cost containment
- Health care administration
- Health care costs
- Health care delivery
- Health insurance
- Health service needs
- Intake interview
- Long term care
- Managed care
- Needs assessment
- Nursing process
- Outreach programs
- Social casework
- Treatment duration
- Treatment planning
- Utilization review
- Medical case management
References & Bibliography
- Case Management Society of America. Definition of Case Management. URL accessed on 2007-01-13.
- William F. Bluhm, "Group Insurance: Fourth Edition," Actex Publications, Inc., 2003 ISBN 1-56698-448-3
- Peter R. Koongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001 ISBN 0-8342-1726-0
- Harris,M. & Bergman,H. C. (Eds.), Case management for mentally ill patients: Theory and
practice.Chronic mental illness, Vol 1. Langhorne, PA, US: Harwood Academic Publishers/Gordon & Breach Science Publishers.
- Aberg-Wistedt, A., Cressell, T., Lidberg, Y., Liljenberg, B., Osby, U. (1995). Two-year outcome
of team-based intensive case management for patients with schizophrenia, Psychiatric Services, 46, 1263-6.
- Bigelow, D.A., Young, D.J. (1991). Effectiveness of a case management program. Community Mental Health Journal, 27, 115-23.
- Bond, G.R., Miller, L.D., Krumwied, R.D., & Ward, R.S. (1988). Assertive case management in
three CMHCs: a controlled study. Hospital and Community Psychiatry, 39, 411-418.
- Burns, R., Creed, F., Fahy, T., Thompson, S., Tyrer, P., White, I. (1999). Intensive versus
standard case management for severe psychotic illness: a randomised trial. The Lancet, 353, 2185-89.
- Byford, S., Fiander, M., Barber, J.A., Thompson, S.G., Burns, T., Van Horn, E. et al. (2000).
Cost-effectiveness of intensive v. standard case management for severe psychotic illness. UK700 case management trial. British Journal of Psychiatry, 176(JUN.), 537-543.
- Chan, S., Mackenzie, A., & Jacobs, P. (2000). Cost-effectiveness analysis of case management
versus a routine community care organization for patients with chronic schizophrenia. Archives of Psychiatric Nursing, 14(2), 98-104.
- Clark, R.E., Drake, R.E., Teague, G.B. (1993). The costs and benefits of case management. In M.
Harris,H. C. Bergman, (Eds.), Case management for mentally ill patients: Theory and practice.Chronic mental illness, Vol 1. (pp. 217-235). Langhorne, PA, US: Harwood Academic Publishers/Gordon & Breach Science Publishers.
- Curtis, J.L., Millman, E.J., Struening, E., D'Ercole, A. (1992). Effect of case management on
rehospitalisation and utilisation of ambulatory care services. Hospital and Community Psychiatry, 43, 895-9.
- Curtis, J.L., Millman, E.J., Struening, E., D'Ercole, A. (1996). Deaths among former psychiatric
inpatients in an outreach case management program. Psychiatric Services, 47, 398-402.
- De-Cangas, J.P.C. (1995). Psychiatric nursing assertive case management: a comprehensive
evaluation of the effectiveness and outcomes of hospital based treatment versus a nurse directed assertive case management program. [[International Journal of Psychiatric Nursing Research]], 1, 72-81.
- D'Ercole, A., Struening, E., Curtis, J.L., Millman, E.J., Morriss, A. (1997). Effects of diagnosis,
demographic characteristics, and case management on rehospitalisation. Psychiatric Services, 48, 682-88.
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mental health case management: results of a national survey. Journal of Mental Health Administration, 22, 101-12.
- Ford, R., Beadsmoore, A., Ryan, P., Repper, J., Craig, T., Muijen, M. (1995). Providing the
safety net: Case management for people with a serious mental illness. Journal of Mental Health, 4, 91-7.
- Ford, R., Rafferty, J., Ryan, P., et al. (1997), Intensive case management for people with serious
mental illness-site 2:cost-effectiveness. Journal of Mental Health, 6, 191-199.
- Ford, R., Ryan, P., Beadsmoore, A., Craig, T., Muijen, M. (1997). Intensive case management
for people with serious mental illness- site 2: clinical and social outcome. Journal of Mental Health, 6, 181-90.
- Franklin, J., Solovitz, B., Mason, M., et al. (1987). An evaluation of case management. American
Journal of Public Health, 77, 674-678.
- Goering, P.N., Wasylenki, D.A., Farkas, M., Lancee, W.J., Ballantyne, R. (1988). What
difference does case management make? Hospital and Community Psychiatry, 39, 272-6.
- Hassiotis, A., Ukoumunne, O.C., Byford, S., Tyrer, P., Harvey, K., Piachaud, J. et al. (2001).
Intellectual functioning and outcome of patients with severe psychotic illness randomised to intensive case management. Report from the UK700 trial. British Journal of Psychiatry, 178, 166- 171.
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Controlled trial. British Journal of Psychiatry, 172, 19-22.
- Hu, T.W., & Jerrell, J.M. (1998). Estimating the cost impact of three case management
programmes for treating people with severe mental illness. British Journal of Psychiatry, (Supp.l 36), 26-32.
- Issakidis, C., Sanderson, K., Teesson, M., et al. (1999). Intensive case management in
Australia: a randomised controlled trial. Acta Psychiatrica Scandinavica, 99, 360-367.
- Jerrel, J.M., Hu, T.W. (1989). Cost-effectiveness of intensive clinical and case management
compared with an existing system of care. Inquiry, 26, 224-234.
- Johnston, S., Salkeld, G., Sanderson, K., Issakidis, C., Teesson, M., Buhrich, N. (1998).
Intensive case management: a cost effectiveness analysis. [[Australian and New Zealand Journal of Psychiatry]], 32, 551-559.
- Knight, R.G., Carter, P.M. (1990). Reduction of psychiatric inpatient stay for older adults by
intensive case management. [[[The Gerontologist]], 30, 510-5.
- Macias, C., Kinney, R., Farley, O.W., Jackson, R., Vos, B. (1994). The role of case management
within a community support system: partnership with psychosocial rehabilitation. [[Community Mental Health Journal]], 30, 323-39
- Marshall, M., Gray, A., Lockwood, A., & Green, R. (2002) Case management for people with
severe mental disorders (Cochrane Review). In The Cochrane Library, Issue 3, Oxford: Update Software. McFarlane, W.R., Stastny, P., & Deakins, S. (1992). Family-aided assertive communitytreatment: a comprehensive rehabilitation and intensive case management approach for persons with schizophrenic disorders. New Directions for Mental Health Services, 53, 43-54.
- McGurrin, M.C., Worley, N. (1993). Evaluation of intensive case management for seriously
and persistently mentally ill persons. Journal of Case Management, 2, 59-65.
- Modcrin, M., Rapp, C., Poertner, J. (1988). The evaluation of case management services with the chronically mentally ill. Evaluation and Program Planning, 11, 307-14.
- Morse, G.A., Calsyn, R.J., Klinkenberg, W.D., Trusty, M.L., Gerber, F., Smith, R., et al. (1997).
An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatric Services, 48, 497-503.
- Nelson, G.S. (1995). Changes in rates of hospitalization and costs savings for psychiatric
consumers participating in a case management program. Psychosocial Rehabilitation Journal, 18(3), 113-123.
- Okpaku, S.O., Anderson, K.H., Sibulkin, A.E., Butler, J.S., Bickman, L. (1997). The
effectiveness of a multidisciplinary case management intervention on the employment of SSDI applicants and beneficiaries. Psychiatric Rehabilitation Journal, 20, 34-41.
- Preston, N.J., & Fazio, S. (2000). Establishing the efficacy and cost effectiveness of community
intensive case management of long-term mentally ill: a matched control group study.Australian & New Zealand Journal of Psychiatry, 34(1), 114-121.
- Rossler, W., Loffler, B., Fatkenheuer, A., & Riecher-Rossler, A. (1995). Case management for
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- Schmidt-Posner, J., Jerrel,l J. M. (1998). Qualitative analysis of three case management
programs. Community Mental Health Journal, 34, (4) 381-392.
- Scott, J. E. D. (1995). Assertive community treatment and case management for schizophrenia.
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- Solomin, P., & Draine J. (1994). Family perceptions of consumers as case managers.Community Mental Health Journal, 30, 165-76.
- Solomon, P., & Draine, J. (1994). Satisfaction with mental health treatment in a randomized
trial of consumer case management. Journal of Nervous and Mental Disease, 182, 179-84.
- Solomon, P., Draine, J. (1995). Consumer case management and attitudes concerning family
relations among persons with mental illness. Psychiatric Quarterly, 66, 249-61.
- Surles, R. C., Blanch, A. K., Shern ,D. L., & Donahue, S. A. (1992). Case management as a
strategy for systems change. Health Affairs, 11, 51-163.
- Wolff, N., Helminiak, T. W., Morse, G. A., Calsyn, R. J., Klinkenberg, W. D., & Trusty, M. L.
(1997). Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients. American Journal of Psychiatry, 154, (3) :341-348.
- Case Management Society of America
- On the Case from minoritynurse.com
- Case management associations at the Open Directory Project
- Resolve Case Management Software
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