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Case management, disease management, demand management, discharge planning, utilization review — at times these functions are so interwoven that it is difficult to know where one ends and the other begins. To add to the confusion, in many cases a single professional performs these varied functions, according to the American Health Consultants/Case Management Society of America 2000 Case Management Caseload Survey.
Specifically, the survey found:
|Table: Percentage of Time Case Managers Spend on Tasks Not Components of Case Management Process|
"This is not at all surprising," notes Sandra L. Lowery, RN, BSN, CRRN, CCM, president of CCMI Associates, an independent case management company in Francestown, NH, and immediate past national president of the Case Management Society of America (CMSA) in Little Rock, AR. "Various practice settings combine or include case manager roles with other roles such as demand management, disease management, or utilization review."
In many cases, the case management role grew out of other existing roles within organizations, explains Carrie Engen Marion, RN, BSN, CCM, president of Advocare/Triage in Naperville, IL. "Many programs started in utilization review and branched into case management because they believe it is an extension of utilization review," she notes. "This has proved to be a problem, because case management is completely different than utilization review. In those organizations, the case management being done is typically of poor quality.
"Many organizations are using a hybrid of case management and utilization review called utilization management. It varies from organization to organization how much actual case management is involved," adds Marion. "Many times there is no case management whatsoever; there may be some discharge planning but it is very short-term."
Case Management Advisor polled national case management leaders and synthesized their responses to develop definitions for these roles in order to clarify what is and what is not case management. Those definitions are:
— Case management. Our experts agree that the CMSA’s definition of case management remains the most comprehensive and concise description of the case management role. It reads: "Case management 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."
— Disease management. Disease management identifies an at-risk population and emphasizes prevention of exacerbations and complications using cost-effective practice guidelines and patient empowerment strategies. Such strategies include self-management in a collaborative practice model that includes physicians and support-service providers. Disease management also encompasses patient self-management education, process and outcomes measurement, evaluation, and management. It continually evaluates clinical and economic outcomes with the goal of improving overall health.
— Demand management. Demand management is an information center that people telephone and receive screening; referrals to appropriate health care services, including case management; assistance; education; and monitoring. "Demand management can, and often does, provide screening and referrals for case management programs," says Lowery. "Alternately, demand management actually can be a less intense model of case management, following the six steps of the case management process."
Marion worked with an organization to follow up on its demand management programs. "Few, if any, demand management programs provide follow-up, when, for example, an individual is directed to go to the emergency room, or call 911. We had a case manager follow up on those calls to identify potential patients who may require some form of management. In this manner, demand management serves as an identification vehicle for individuals who may need case management or disease management."
— Utilization review. Utilization review is the review of health care resources in order to ensure that resources are used appropriately and in a cost-effective manner. "There are inherent conflicting principles involved in performing both utilization review and case management," cautions Lowery. "This should be recognized by anyone developing a dual model. There is a different skill set required for utilization review and case management, and the practitioner and their manager will find that an individual rarely can perform well in both roles," she notes. "This sets up a lose-lose scenario for the practitioner and the organization."
"Utilization review is very guidelines-oriented without a lot of judgment required," adds Marion. "Case management requires both creativity and judgment. In my experience, a nurse who likes utilization review will hate case management, and vice-versa."
Historically, many hospitals have incorporated case management into other staff job titles, but kept those staff’s tasks the same, notes Marion. "Case managers incorporate aspects of discharge planning, disease management, utilization review, and maybe even demand management into their everyday practices," she explains. "The reverse is not true."
In an efficient case management program, "the case manager will do the utilization review and the discharge planning in collaboration with the treatment team and the physician and the patient," she continues. "Case managers will also incorporate elements of disease management into the program, because case managers should be providing education and compliance monitoring as part of the case management process."
In some systems, "case managers are called upon to do many other jobs," explains Marion. "The problem comes when these other strategies are used in place of case management or when the case manager is not adequately trained as a case manager. A nurse trained in utilization review makes a poor case manager."
Case management is not interchangeable with other resource management strategies such as utilization review, cautions Marion. "Sometimes, there is a negative impact because the organization requires the health care professional to manage many cases, which can lead to problems with time management and the inability to serve the case management needs of the patients. At other times, the case manager is so tied up with authorizations and the need to satisfy other system requirements that the patient’s needs get lost.