Implementing Case Management Programs

Case management systems have been shown to be effective at reducing overcrowding and improving patients’ quality of life. In 2013, CMS began paying bonuses to or extracting penalties from hospitals depending on their overall quality of care. Case managers are some of the most vital staff members in improving the quality of care and overall patient experience while they are in the hospital. Case management systems are adaptive to many settings and improve outcomes, reduce readmission risks, eliminate avoidable days, enhance claims management, and boost core competencies under the PPACA (Becker’s Hospital Review). This document serves to provide resources for determining which case management model is best for your facility, how to implement a case management program, and includes a list of the best practices of successful case management programs.

Guiding Principles of Case Management Philosophy

The ‘health and human services profession’ is a broad umbrella term under which case management falls. Case managers typically come from myriad occupational backgrounds such as mental and behavioral health, medicine, nursing, rehabilitation, counseling, and workers’ compensation. Everyone in the service line of the hospital benefits directly or indirectly when their patients’ care is managed and provided efficiently and effectively. Case management is interdisciplinary and an interdependent practice, where a patient is provided holistic advocacy, communication, resources, and education to achieve some level of autonomy. The resources and education given to clients can be based on their cultural beliefs, values, and their needs in collaboration with all their service providers. The services offered by these case managers are spelled out in their clients’ insurance plans. The benefits of facilities who support internal case management processes can include lowered health claim costs (if payor-based), early return to work and reduced absenteeism (if employer-based), and shorter lengths of stay (if acute care-based). These benefits and the services offered by the case managers are optimized in an environment where there is open and direct communication and collaboration throughout the healthcare continuum of case managers, client, client’s support system, the primary care provider, and other involved professionals/paraprofessionals.

Case Management Program Structures

Most case management models work best when they are optimized, applied directly to their environment, and staffed correctly. There are several structures that hospital leadership teams can assess prior to program implementation to ensure that the chosen program is the best fit. Leadership teams will generally consider what challenges their facility faces before choosing a system. There are two theoretical best-practice models that most hospitals choose from to structure their case management departments. These models are intended to be a foundation for hospitals to modify and make their “own” based on their needs and limitations.

  1. Integrated (dyad) model- A single manager is responsible for overseeing all three functions (utilization management care coordination, and discharge planning) for a given patient.
  2. Collaborative (triad) model- Each function is assigned to a separate manager.

Most facilities use a hybrid model where they pick and choose which pieces of these structures fit their needs the best. The three functions of case management are the tip of the iceberg of case manager responsibilities, as outside forces such as economics, legislation, payer structures, labor force, and patient population shifts are also part of this profession.

While it is known that hospitals need nurses and social workers to provide the best possible care to patients, it can be difficult to figure out how to best leverage and accommodate the distinct skills of each profession for an efficient and effective case management model. It is vital for organizations/facilities to put tailored case management practices in place.

Implementing Care Management Programs

The Agency for Healthcare Research and Quality has an example guide for designing and implementing Medicaid disease and care management programs. This document includes information on:

  • Planning a Care Management Program
  • Program Development Considerations, Understanding the Motivation for Program and Establishing Program Goals, Assessing the Financial Environment, Securing Federal Support and Approval, Engaging Stakeholders, Building on Lessons Learned from Other States, and Reviewing Readiness for Care Management
  • Considerations for Program Design
  • Selecting, Identifying, and Enrolling Target Populations
  • Determining Program Interventions
  • Considering Pilot Testing
  • Developing a Measurement and Evaluation Strategy

The Lippincott Nursing Center has a document on The Practice of Hospital Case Management: Past, Present, and Future. This article includes information on:

  • The Health Care Environment: Chronic Illness, Integrated Care Management, and The Social Determinants of Health
  • Practice Background
  • The Current State of Hospital Case Management
  • The Desired State of Case Management: Attributes of Care Coordination, Transformation Priorities, Redesigning the Scope of Services, Establishing Clear Roles and Responsibilities, Developing an Entrepreneurial Structure to Support Care Coordination Goals, Positioning Case Management with a Transformative Executive Sponsor, Realigning for Greater Effectiveness, and Fine-tuning Case Manager Workflow
  • Executive Summary of Case Management
  • A Summary of Key Action Points

Top Hospital Case Manager Best Practices

When hospital teams learn how to choose, create, and implement case management models that fit the needs of their organization and patient population, the line of service becomes more efficient and effective. There are many factors to consider when determining which aspects of the theoretical best-practice models will benefit your facility the most:

  • Organizational focus and goals
  • Product lines
  • Organization’s size
  • Payer mix
  • Labor force
  • Staffing pattern
  • Length of stay
  • Case mix index (CMI)
  • Technology
  • Physicians

*list from Guide House

Care Transition Assessments help administrators and clinicians improve their unique case management models, build well-connected teams, and create effective strategic plans for implementing the new model and sustaining its progress and growth. These assessments are essentially interdisciplinary meetings for honest discussion around the benefits of each case management structure. This is when your facility’s identified case management needs, functions, and responsibilities would come into play for determining which structure is best aligned with the hospital’s goals. This team of individuals from all health professions within the hospital can review patient care standards, your organization’s procedures and guidelines, and patient population breakdowns. The results of these conversations should be understood by all members of this team and agreed upon based on specialization and patient needs. The plan of action from these conversations should be implemented into new employee onboarding processes and sustained in regular staff-to-staff conversations to reinforce collaboration between specializations.