Ingredients of a successful case management program - Case Management

Health care is no longer "business as usual." As we restructure and redesign our health care system, case management's role and value is emerging as a major issue in health care redesign.

The number of Americans over age 65 increased more than 10 times from three million to over 34 million during the 20th century. This change in demographics left a population with significant chronic illness requiring very different care than what is provided by the current acute care delivery system.

In addition, many health systems grew in size and complexity through mergers and acquisitions. This growth created a very complicated system of care for providers and patients. Multiple providers at different locations challenge any attempt to create a seamless continuum.

Physicians who do not know the patients frequently provide care in hospitals,. subacute care facilities and nursing homes. The patients' primary care physicians are often relegated to ambulatory care with the challenging role of communicating and coordinating a diverse group of providers.

Within this complex delivery system, the pressure on health care systems to decrease costs and improve quality continues. At the same time, consumers are demanding care that is responsive, coordinated and seamless. These forces are placing enormous pressures on those administering and delivering health care.

Case management has developed as one method to meet the current demands in the health care environment. However, multiple questions surround the discussion of case management.

* How should it be done?

* What is the population focus?

* How do we finance it?

* How much will it save the institution?

* Why is our case management producing lackluster results?

* How do we ensure its success?

* Should we do it at all?

A review conducted by a large integrated health care system identified nine basic ingredients believed to be fundamental in developing and maintaining a successful case management program.

Nine Ingredients for a Successful Case Management Program

1. Assess Organizational Needs and Capacities

2. Clearly Define "Case Management"

3. Secure Senior Management Support

4. Focus on High Risk

5. Match Case Management Model with Population Needs

6. Manage the Redesign: Involve, Educate and Implement

7. Hire the Right Staff

8. Develop Appropriate Outcome Measures

9. Stick to the Model

I. Assess organizational needs and capacities

It is critical to understand your internal capacity: the financials (the budget you have), information system and delivery system capacity. In other words, the "what" has to be in harmony with the operational and financial "how."

Be clear about what the program will deliver. Case management does not generate revenue. It may produce cost savings through resource protection or cost avoidance. Taken together, it minimizes losses related to cases that are resource intensive. (1) Case management cannot be expected to be self-funding in the traditional sense.

To ask "How much has the program made?" is a signal that the expected outcomes of the program have not been effectively communicated. A thoughtful plan for supporting the informational needs of the case manager program is needed.

For case management to act as an integrating force in the delivery system, quick easy access to information is fundamental. Determining how and when primary care physicians, specialists, hospitals and subacute settings will interact with case management is critical.

2. Clearly define case management

Case management is an overused term. Clearly define what case management is within your organization. It has been described as a "Rorschach test on which is projected any image one wishes." (2)

Case management, as defined by the Case Management Association of America, is "a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual's health needs through communication and available resources to promote quality, cost-effective outcomes." (3)

Quite simply, case management is a strategy to manage a defined population through a 1:1 approach to achieve individualized care. The goal of this care is to coordinate service for the defined population that focuses on linking early intervention, acute care and community-based services with a goal to providing the right care at the right cost in the right place for the right length of time.

Case management is a system of care designed to manage a small percentage of patients because of their special needs. This special group benefits from the individualized care of a case manager to improve access and coordination, reduce duplication, improve outcomes and reduce resource utilization. (4) Every patient needs his or her care managed, however, every patient does not need case management. (5)

Although most health care professionals have a component of case management in their job function, it is not the major focus of their role. Many erroneously classify programs that are primarily utilization review or utilization management as case management programs. (6,7)

These utilization models are "reactive" and place undue emphasis on acute care episodes and crisis management. True case management, to be effective, must be proactive with a focus on preventing health crisis, premature functional decline and unnecessary utilization of costly resources.

In addition, people in roles who perform only components of the case manager job functions are often labeled case managers. Nurses focused on resource coordination, such as obtaining medications for the indigent, arranging transportation, blood pressure re-evaluation and scheduling appointments, do not represent the full scope of case management.

Ultimately, the use of the title "case manager" in such situations may lead to confusion over expectations and outcomes. To avoid role confusion, the title "case manager" should be reserved for only those doing case management.

3. Secure senior management support

To be successful, case management must be integral to the organization's strategic plan and supported by senior management. Commitment to case management is secured by clearly articulating case management's role in the delivery system and linking the goals of the case management program to critical organizational issues.

Commitment by senior management is best judged by the allocation of appropriate resources to the case management program. This may sound obvious; however, many organizations expect to achieve monumental results without investing resources such as staff, training, time and equipment. (6)

Problem patients, infrastructure shortcomings and non-priority goals ultimately become poor rationales for a program. The challenges can be met more efficiently in other ways.

Acknowledged institutional needs and goals are the safest foundation on which to build a program. Programs that fail to meet critical institutional needs will find their foundation sinking and, ultimately, they will fail.

4. Focus on high risk

The focus for the case management program is driven by the institution's "book of business." Segmentation of the population is needed to identify the patients for whom case management would result in improved inpatient and institutional outcomes.

Five to 20 percent of a population with the greatest illness burden are responsible for 70-80 percent of the total populations' health care costs. In a commercial population, chronic illness accounts for 30 percent of the total costs. In an urban Medicare population, the same group of patients account for nearly 60 percent of the costs. (8)

One size fits no one. The population must be identified and the program targeted to it. Substantial illness burden, cost or functional status are criteria commonly used to segment the population. What measure is used to segment the population is a function of the program goals. Regardless of the criteria chosen, the ability or to identify patients who will suffer poor outcomes, decline in health and consume large amounts of resources is not ideal.

In our experience, approximately half of the patients identified as resource-intense consumers of health care in one year will remain so in the next 12 months. Case management programs need both thresholds and processes to both terminate case management for patients who no longer require that intensity of service and to identify new enrollees.

Provider referral, administrative data set mining and health risk assessments used in combination have proven to be the most effective tools for segmentation of the population.

5. Match the case management model with population needs

Choose the correct case management model based on your population needs.

Not all case management models are the same. The model must be designed to meet the needs of the population(s) identified in your population assessment.

As the wellness of a population increases, the opportunity for cost savings per unit of case management intervention decreases. As a result, most programs target high-risk or resource-intense patient populations to maximize the opportunity.

Catastrophic case management such as automobile accident victims and case management of a medically complex, frail, elderly population have different goals and require different case management models. Telephone case management alone may be inappropriate for an ill, medically complex population but may be very appropriate for a chronically ill but stable population.

The intensity of the case management model must be matched to the needs of the population. Case manager to patient ratios will also vary according to population needs. For a catastrophic model ratios of 1:25-30 are common while frail elderly models are 1:30-50.

Tension will always exist to add a few more patients to the caseload to increase the ratios. The correct ratio is a complex function of the strength of your staff, the informational support, the unique characteristics of the population and program goals. Ratios, represent the starting point of the discussion, not the final word.

6. Manage the redesign: involve, educate and implement

Successful case management requires process reengineering. If case management is pursued as an add-on, the results will be modest at best. To make the necessary delivery system changes, an effective relationship must be developed with the physicians of the delivery system.

An excellent overview of practical steps to a win-win relationship with physicians is available elsewhere. (9) Understanding the practice setting, developing credibility, establishing effective communication channels and building collaborative relationships are needed for successful implementation of a case management program.

A process facilitator and a clinical champion are necessary for successful implementation. For a large program, eight to 12 months should be allotted for implementation. Rome was not built in one day and neither will a case management program.

Implementation should be well underway in six to eight months. A clear appropriate charter that defines the boundaries, constraints, deliverables and direction is imperative. For all the time, energy, and effort spent on implementation, the investment pales in comparison to the resources consumed by an unsuccessful program.

7. Hire the right staff

A common pitfall is the belief any nurse can assume a case manager's role. "Case management is not for the faint of heart. It is not for those seeking to avoid the stress of the hospital setting."9 Case managers require a very special skill set. Commitment to the role, clinical expertise, critical thinking skills, flexibility, creativity and strong interpersonal skills are a few of the role requirements.

Pick strong staff members, give them capable leadership and you will be rewarded with success.

8. Develop appropriate outcome measures

Case management, like all health care interventions, must develop appropriate outcome measurements. Meeting and exceeding customer, staff and top management needs are vital for long-term viability of the program.

Performance measures should ultimately link the organizational measures such as market share, medical loss ratio and the outcomes of case management including:

* Decreased fragmentation

* Cost containment

* Improved quality and satisfaction with care delivery

Outcome measures should be collected on individual patients, targeted groups and the overall program. Cost benefit analysis reports identifying interventions and savings--both actual and potential--have been used to effectively demonstrate clinical outcomes and cost effectiveness. (9)

Patient profiles tracking information on average age, gender, living arrangements, medical conditions and number of medications allows for an understanding of the population requiring case management and their health issues.

Resource utilization including hours of case management, hospital admissions, emergency room visits, home care and nurse home days are essential. Satisfaction surveys should be collected on patients and families as well as the physician and health team.

9. Stick to the model

Without a clearly defined role, case managers often become grease for the tight spots in the delivery system, appointment expediters for chronically overbooked clinics, and an extra pair of hands for staff-depleted ambulatory settings.

The case managers are part of care team and care management system. They are not a substitute for a poorly functioning care team or weak providers and will not solve all your delivery system problems.

Layering extraneous clinical duties and responsibilities on a case manager, diluting their effectiveness by assigning an unrealistic number of patients and wishful thinking concerning "part-time" case management are common routes to poor results.

To ensure the right care in the right place at the right cost, the case management program should be matched with the intensity of the patient needs. Case management is not a panacea. Thoughtful integration of the role and function will produce results.

References

(1.) Rantz, M. and Bopp, K. "Issues of Design and Implementation from Acute care, Long-Term care and Community-based Settings." Nurse Case Management in the Twenty-First Century. Elaine Cohen (Ed). St. Louis, Mo. Mosby, 1996, pp.181-188.

(2.) Rubin, A. "Case Management." Encyclopedia of Social Work. New York, Springer, 1986, pp. 212-222.

(3.) Case Management Association of America. Standards of Practice for Case Management. Little Rock: CMSA, 1995.

(4.) Zander, K. "Case Management Designed for the Care Continuum." Managing Outcomes Through Collaborative Care: The Application of Care Mapping and Case Management. The Center for Case Management, American Hospital Publications, 1995.

(5.) Bower, K. and Falk, C. Unpublished case management seminar material. Carondeler Health Care System. Tucson, Ariz, 1993.

(6.) Aliotta, S. "Components of a Successful Case Management Program." Managed Care Quarterly. Spring 1996, 4:2, pp. 38-45.

(7.) Rossi, P. Case Management in Healthcare: A practical guide. Philadelphia, W.B. Saunders, 1999.

(8.) Maher, K. and Lutz, J. "Identifying Opportunities to Improve the Management of Care: A Population- based Methodology." Journal of Ambulatory Care Management. April 1997, 20:2, pp.18-36.

(9.) Mullahey, C. The Case Manager's Handbook. Second Edition.

Reginald F. Baugh, MD, is president of Quality Healthcare Providers, P.C. a multi-state facility based practice based in Dearborn Mich. He has worked in academic medical centers, managed care organizations and medical group practices. He can be reached by phone at (313) 996-3980 or by email at rbaugh@qualityhealthcareproviders.com.

Michelle Freeman, MSN, RN is the director of initiative effectiveness, quality support services for the Henry Ford Health System in Detroit, Mich. She can be reached by phone at (313) 876-9269 or by e-mail at mfreema2@bfbs.org

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