Case Management Outcomes: Are We All Speaking the Same Language?

Michal Boyd , RN, ND, FCNA(NZ)

Nurse Practitioner – Aged Care Primary Health, Waitemata DHB

Senior Lecturer, Auckland University of Technology

Overview of Case Management Outcome Literature

Over the past 25 years, there has been an abundance of literature regarding nurse case management intervention. In fact, when “case management” is entered as a key word in the Medline database, over five thousand references appear. A review of the case management literature reveals wide variation in the outcomes reported. Some articles report great success in reducing health care costs with the implementation of case management, and yet there seems to be just as many that report that case management made no impact at all. Some report the intervention actually increased the health care utilisations and cost. Care coordination plays a large role in the Health of Older Peoples Strategy and is part of many DHBs intervention for high risk older people. The purpose of this discussion to articulate the many variations in case management models and factors that can influence the outcomes of this intervention.

In general, the term case management refers to acting as coordinator and manager for a group of clients or patients. Huber (2002) states that case management generally manages risk and coordinates care as a core function. What is actually done beyond this is extremely variable. In health care, the term has been used to describe interventions provided in a wide variety of settings and to describe a wide variety of models of care. Therefore, comparing case management models and their outcomes is not possible out of context and it is therefore extraordinarily difficult to compare outcome data reported in the literature.

One of the main difficulties with the case management literature is what Lamb refers to as the “black box” effect of case management (Lamb, 1992). The outcomes of case management are reported without attention to the detail of the case management intervention itself. For instance, there is often little discussion about how patients are assessed for case management. There is rarely a description about the level of expertise and background of the case manager and what is actually done as part of the intervention itself. The lack of description of the intervention assumes that case management is an objective entity that can be compared across providers, settings, geographic areas and patient populations. The fundamental flaw with this approach to reporting outcomes is the assumption that a case management trial is similar to a medication trial where the intervention is objectively the same across settings. Case management programs are extremely variable, and often the term case management can be a wide variety of interventions.

Different Models of Case Management

Many people with extremely complex situations “fall between the cracks” in the health care system due to fragmentation and lack of integration of their care across settings and multiple providers. Such fragmentation often results in duplications and gaps that compromise the care provided for the patient and their whanau/family and is costly for the health care system. Case management interventions in health care have evolved to provide coordinated and efficient care for those that fall outside the norm, particularly in the last three decades. There are many different models of case management in practice. Generally, there is a continuum of models between those that are mainly individual patient focused and those that are focused on improving the efficiency of the health care system in which all patients interact (see figure 1). The individual focused case management models often focus on the 5-10% of patients that have complex needs and have fallen off the normal patient care pathway. Case finding is an extremely important component of this type of care coordination. Systemic focused case management aims to increase the efficiency of the health care system for all patients, which may involve the development of protocols and system standards. Both extremes on the continuum are needed for efficient and effective care coordination because they provide a balance between patient advocacy and system efficiency (Lamb, 1992).

Often, individual case management models incorporate different aspects of the entire case management continuum. Bower (1992) succinctly summed up the care coordination continuum by stating “everyone's care needs to be coordinated, but not everyone needs a care manager.” The crucial point for all case management programs is to clearly define what outcome the intervention is seeking to improve and if this improvement requires individual patient intervention, systematic intervention or both.

Figure 1: Continuum of Case Management Models

The following is a review of case management models to illustrate the different characteristics of various interventions.

Acute Care Case Management : These case managers may combine individual and systemic case management duties. The focus of activity is to make sure the right sequence of events occurs during the acute care hospital stay to decrease fragmentation, duplication of services and gaps in care, in order to decrease hospital length of stay (Cook, 1998; Kim & Soeken, 2005).

Brokerage Case Management Models: This type of case manager matches client need with available resources. To provide this type of care, the case manager must be involved in case finding activities as well as perform a comprehensive assessment and develop a plan of care that will provide the client with the best match of needs and resources.

Disease State Management/Chronic Illness Case management: High cost and high volume chronic illnesses are often the focus of this case management role. The case manager works closely with the patient and their family to help facilitate self- management of their condition. The care manager may also follow the patient across the entire journey through all health care settings (Aubert et al., 1998; Couch, Sheffield, Gerthoffer, Ries, & Hollander, 2003; Taylor et al., 2005).

High Needs Older Adult Care Management: Chronically ill o lder adults are the most costly health care consumers and have been a main target of case management intervention for the past three decades. The compounding issues of decreased functional ability and multiple co-morbidities result in multiple interfaces with the health care system. By identifying high-risk older adults and targeting specific interventions for their needs, it is possible to prevent critical incidents and thus decrease readmissions. Comprehensive geriatric assessment is an essential component of this type of care. Coordinated multidisciplinary team care plans lead to improved function and better health outcomes for elderly patients. These models often employ a nurse case manager that works with older people in the community in coordination with primary care (Lamb & Stempel, 1994; Schraeder & Britt, 1997; Stuck, Aranow & Steiner, 1995; Nikolaus, Specht-Leible, Bach, Oster & Schlierf, 1999).

Gatekeeper Roles: The role of the case manager as gatekeeper is really a role to provide an efficient health care system. This is in essence an advocate for the health care system rather than the individual person. Their role is to make sure the most efficient use of the health care dollar occurs with the resources available. Often there is a negotiation process between the case managers in a gatekeeper role and the case manager in a more purely patient advocate role. As was discussed previously, both ends of the case management continuum are needed to keep a balance between patient need and system efficiency.

It is clear there are many variations of the case management theme. This has created difficulties for meta-analysis of these programs because the intervention itself has often not been described thoroughly, and therefore interventions have a wide variation in outcomes.

Effective Case Management Characteristics

A comprehensive literature review commissioned by the NHS Modernisation Agency (Singh, 2005), summarises several important factors for case management effectiveness. For instance, it is essential that care management be carried out across health care settings, from primary to secondary care and back to primary care. It is also imperative that the case manager has the ability to negotiate and collaborate with families, physicians, and the entire multidisciplinary team. The case manager requires strong teaching, counselling and patient advocacy skills. For high needs individuals, specialist advanced practice nursing knowledge and skills and the ability to coordinate complex therapeutic regimes is required. For effective case management interventions, assessment of individual need is essential and the best case management systems take a “whole systems” approach that includes collaboration between health and social services. Nurses also have a central role to play in care of long term conditions, whether in primary or secondary care (Stuck, Beck & Egger, 2004).

Summary of Case Management Models

Case management outcome studies have largely focused on increasing cost effective care regardless of the population served or the model employed. This has resulted in a wide range of outcomes which are difficult to compare. In addition, the outcomes cannot be compared because of the lack of adequate description of case management interventions, that is, the actual case management intervention is often unknown and not well described (Lamb, 1992).

However, there are several case management characteristics that have emerged in the past decade that point to building effective case management interventions:

The health care system requires interventions to increase the efficiency for all consumers.
An assessment is needed to identify those that, regardless of overall health care system efficiency, require individual coordination intervention.
Case Management interventions need to follow the patient's journey across the continuum of health care settings.
Specialist knowledge by the case manager enhances their ability to improve outcomes.
It is important for the case manager to “work themselves out of a job” by empowering the consumer and their whanau/family to take control and coordinate their own care with coaching from the patient advocate. (Stuck, 2004; Brooten & Naylor, 2002).

Although the outcome data for case management is mixed overall, it has been shown to be effective if implemented in a way that balances patient advocacy and system efficiency to benefit consumers and their whanau/family.

References:

Aubert, R.E, Herman, W.H., Waters J., Moore W., Sutton D, Peterson B.L., Baily C.M., & Koplan, J.P. (1998). Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Ann Intern Med, 129 (8), 605–612.

Bower, K.A. (1992). Case Management by Nurses . Kansas City , Missouri : American Nurses Publishing.

Brooten, D., Naylor, M.D., York , R., Brown, L.P., Munro, B.H., Hollingsworth, A.O., Cohen, S.M., Flinkler, S., Deatrick, J., Youngblut, J.M. (2002). Lessons learned from testing the quality cost model of advanced practice nursing ( APN ) transitional care. Journal of Nursing Scholarship, 34(4), 369-375.

Cook, T. (1998). The effectiveness of inpatient case management: Fact or fiction? Journal of Nursing Administration, 28 (4), 36-46.

Couch, C., Sheffield , P., Gerthoffer, T., Ries, A., & Hollander, P. (2003). Clinical outcomes in patients with type 2 diabetes managed by a diabetes resource nurse in a primary care practice. Proc. Bayl Univ Med Cent, 16 (3), 336–340.

Huber, D.L. (2002). The diversity of case management models. Lippincott's Case Management, 7 (6), 212–220.

Kim, Y., & Soeken, K. L. (2005). A meta-analysis of the effect of hospital-based case management on hospital length of stay and readmission. Nursing Research , 54(4), 255-264.

Lamb G.S. (1992). Conceptual and methodological issues in nurse case management research. Advances in Nursing Science. 15 (2), 16-24.

Lamb, G.S., & Stempel, J.E. (1994). Nurse case management from the client's view: Growing as the insider-expert, Nursing Outlook, 42 (1), 7-13.

Naylor, D. & Brooten, D. (2002). Advanced practice nurses in transitional care. Journal of Nursing Scholarship, 34 (4), 369.

Nikolaus, T., Specht-Leible, N., Bach, M., Oster, P., Schlierf, G. (1999). A randomized trial of comprehensive geriatric assessment and home intervention in the care of hospitalized patients , Age and Ageing, 28 (6), 543-551.

Schraeder, C., & Britt, T. (1997). The Carle Clinic. Nursing Management, 28 (3), 32-34.

Singh, D. (2005). Which staff improves care for people with long-term conditions? A rapid review of the literature. NHS Moderisation Agency & Health Services Management Centre: Birmingham , England .

Stuck, A.E., Egger, M., Hammer, A. and Minder, C.E., Beck J.C. (2002). Home visits to prevent nursing home admission and functional decline in elderly people: systematic review and meta-regression analysis. JAMA 287 , 1022–1028.

Stuck, A.E., J.C. Beck, and M. Egger, (2004). Preventing disability in elderly people . Lancet,. 364 (9446), 1641-1642.

Taylor , S.J.C., Candy, B., Bryar, R.M., Ramsay, J., Vrijhoef, H.J.M., Esmond, G., Wedzicha, J.A., & Griffiths, C. J. (2005). Effectiveness of innovations in nurse led chronic disease management for patients with chronic obstructive pulmonary disease: systematic review of evidence. BMJ, 331 , 485-402.