Case management has become the standard method of managing health care delivery systems today. In recent decades, case management has become widespread throughout healthcare areas, professionals, and models in the United States; and it has been extended to a wide range of clients (Park & Huber, 2009). The primary goal of case management is to deliver quality care to patients in the most cost effective approach by managing human and material resources. The focus of this paper is on the concept of case management and how it developed historically, the definition of case management, the components of case management, and how it relates to other nursing care delivery models.
History of Case Management
The concept of Case management has was first introduced in the 1970’s by insurance companies as a way to monitor and control costly health insurance claims, commonly created by a catastrophic accident or illness (Jacob & Cherry, 2007). Today almost every major health care organization has a case management program managing and directing the use of health care services for their clients. Also, case management by payer organizations is recognized as external case management.
Hospitals recognized the need for the case management model in the mid 1980’s to manage the lengths of stay of hospitalized patients and the treatment plans (Jacob & Cherry, 2007). In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals had to efficiently manage the treatment provided to a client and reduce the client’s length of stay (Jacob & Cherry, 2007). Case management, or internal case management “within the walls” of the health care facilities was created to streamline costs while maintaining quality care (Jacob & Cherry, 2007).
Hospitals felt the pinch of payment shortfalls in the early to mid-1990s resulting from the prospective payment program (Daniels & Frater, 2011). Because of this dramatic change in organizational culture which engaged hospital employees and physicians in cost savings and delivery of care efficiencies, hospital governing bodies explored the consulting world to help rein in costs and reduce the length of stay of patients (Daniels & Frater, 2011). During this time many hospitals many hospitals recognized a new financial reality and had to downsize, reduce staff, or simply close (Daniels & Frater, 2011). Hospital case management programs then began to proliferate because of this period of industry turmoil.
Case Management Defined
Several experts and health care organizations have defined case management; although, there is no standardized definition for case management (Finkelman, 2006). Case management is a...