By Toni Cesta, PhD, RN, FAAN
Introduction
Case management is not a new concept. It has been around for more than 90 years. As a means of providing care, it originated in the 1920s out of the fields of psychiatry and social work and focused on long-term, chronic illnesses that were managed in the outpatient, community-based settings. Case management processes also were used by visiting nurses in the 1930s. The original public health nursing models used community-based case management approaches. As a care delivery system, case management is a relatively new concept to the acute care setting, having developed and flourished in the mid-1980s. Between the 1930s and the 1980s, the model remained essentially in the community setting. It was not until the introduction of the prospective payment system that the model shifted to the acute care, hospital-based setting.
This month, we will review case management’s long and rich history from a community-based model to an acute care model and beyond. In fact, case management now can be found in virtually every practice setting across the continuum of care.
Early Community-based Case Management
Case management, although more commonly thought of as an acute or hospital-based model, has its roots in the community. Long before hospitals were considered the center of the healthcare universe, case management was used for a variety of purposes and to meet the needs of diverse populations of patients.
Case management has roots in public health nursing, social work, and behavioral health. There is evidence of case management in the 1860s, where such techniques were used in the settlement houses occupied by immigrants and the poor. “Patient care records” consisted of cards that catalogued the individual’s and family’s needs and/or follow-up needs, all aimed at ensuring that the patient/family received the services they needed and that additional services would be provided as necessary.
Another example of a case management application, also in the 1860s, was the first Board of Charities established in Massachusetts. Aimed toward the sick and the poor, public human services were coordinated with a primary goal of conserving public funds. Even in the 1860s, cost containment was a concern as it related to the distribution of public funds to the poor. Social workers were responsible for managing these processes.
In the early 1900s, case management strategies were implemented by public health nurses at Yale University School of Nursing. A collaborative effort was established between a clergyman and the superintendent of the school. The clergyman described the nurse’s role and the requirements he sought in the following ways:
- knowledge and expertise;
- communication skills;
- cost containment;
- collaboration with physicians;
- appropriate allocation of resources;
- responsibility for overall care of the patient and family;
- provision of emotional and psychosocial support and the assurance of a dignified and peaceful death;
- coordination and management of care;
- facilitation of the delivery of patient care activities;
- obtaining funds for special programs.
Review a contemporary case manager’s job description and you are likely to find the superintendent’s expected role functions and requirements there.
Around the same time that public health nursing was embracing case management concepts and techniques, the field of social work was using care coordination techniques with a focus on linking patients and families to available resources. Social work began to emerge as the discipline focused on linking or brokering healthcare services for individuals. Conversely, the early nursing case management models included both coordination and care delivery functions. In many ways, these differences remain in the approaches taken by both disciplines in the delivery of contemporary case management.
In the 1950s, behavioral health workers began using case management tools and strategies. Targeted were World War II veterans who presented mental and emotional conditions in addition to physical disabilities. The “continuum of care” was labeled for the first time, relating to the myriad community health services these patients required and used. Behavioral health case managers accessed, coordinated, and ensured that service needs were met on a continuous basis. These strategies still can be found today in many behavioral health models of care delivery.
The 1970s and 1980s
During the 1970s and 1980s, the federal government provided funding to support the development of several demonstration projects focused on long-term care. Legislation was enacted at the state and federal levels to incorporate these projects into strategic planning policies. Reimbursement was established through Medicare and Medicaid waivers. Some of the better-known projects included the Triage Program in Connecticut, the Wisconsin Community Care Organization, the On Look Project in San Francisco, the New York City Home Care Project, and the Long-Term Care Channeling Demonstration Project in San Francisco.
By the late 1980s, community-based case management programs were emerging in many parts of the country as a mechanism for managing patients and resources in capitated environments. One important example is the Carondelet Saint Mary’s Model in Tucson, AZ. These emerging and contemporary models returned case management to its original roots: the community. Case management had completed a circle that took more than 100 years to circumnavigate.
The 1990s
As a result of the re-emergence of community-based case management, the Centers for Medicare & Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA), funded five demonstration projects that used registered professional nurses in the role of community case managers to coordinate care for Medicare beneficiaries. These projects were called community nursing centers, including the following:
- The Carle Clinic at the Carle Organization in Urbana, IL.
- A School-Based Health Center at The University of Rochester in New York.
- The Silver Spring Community Nursing Center at the University of Wisconsin, Milwaukee.
- The University Community Health Services Group Practice at Vanderbilt University in Nashville, TN.
- The Carondelet Health Care Corporation at Carondelet St. Mary’s Hospital in Tucson, AZ.
A special feature of these centers is that they relied on nurses as the main providers of care with physicians in consulting roles. These centers demonstrated the ability to affect both the process and outcomes of care. Examples of the services provided or arranged for and coordinated by the nurse case managers were health risk assessments; authorization, coordination, evaluation, and payment of services; services such as home care, transportation, respite care, and home-delivered meals; preventive and psychiatric mental health; health promotion activities such as exercise, nutrition, and lifestyle changes; durable medical equipment; and medical or minor surgical care.
Changes in Reimbursement
While case management principles could be found in a variety of community-based settings before the 1980s, case management was not widely used or well understood. It was not until the 1980s that case management truly came into its own. Before 1983, healthcare costs were not of major concern to the healthcare provider. Because most healthcare reimbursement was based on a fee-for-service structure, there were no financial incentives to reduce costs. In fact, because the use of resources was financially rewarded by the healthcare system, overuse abounded. This overuse and misuse of healthcare resources, particularly those in the acute care setting, resulted in spiraling costs for the consumers of care and the insurers who were paying for it. The costs of pharmaceuticals, radiology, and supplies continued to escalate with minimal management. By the 1990s, healthcare in the United States had become a trillion-dollar business.
Therefore, it is no great surprise that the healthcare system eventually broke down. Consumers and third-party payers no longer were willing to pay high costs when the quality of the services they were receiving was barely keeping pace. In fact, it appeared to most healthcare consumers that the quality of services was diminishing and the value of care was reduced. The costs were rising while value was falling.
The mid-1980s were witness to a flurry of activities, all designed to figure out how to improve the quality of healthcare while reducing costs. The expected result was an increase in value. On the payer side, we first saw the introduction of the prospective payment system with the diagnosis-related groups (DRGs) as the reimbursement scheme. Shortly after that, the western United States saw an increase in the use of managed care and health maintenance organizations (HMOs). Employers saw HMOs as a way to lower the cost of providing health insurance to their employees. Several states, including Minnesota, California, Arizona, and Tennessee, have since adopted broad-based managed care programs. By the turn of the 21st century, managed care reimbursement systems had permeated the United States.
Unfortunately, many of the efforts resulting in changes in reimbursement and the introduction of managed care were perceived solely as cost-cutting. Although much lip service was given to the notion of quality, effective and consistent outcome measures as well as measures of quality of care, were lacking. What did exist were financial parameters that guided outcomes evaluation, such as length of stay and cost per case. Within three to five years, organizations began to recognize the need to incorporate quality into the agenda. Much of this came out of healthcare organizations themselves.
Two major quality improvement models drove the quality initiatives. The first was total quality management and the use of continuous quality improvement methods. The second was case management. Ultimately, both these concepts became the framework for redesign efforts and patient-focused care.
Early Hospital-based Case Management
Two hospitals attempted to respond to the changing times by addressing the changes in healthcare reimbursement, shortened lengths of stay, and dwindling hospital resources. Carondelet St. Mary’s Hospital in Tucson, AZ, and New England Medical Center in Boston, were the first to recognize the need to redesign their nursing departments. Each introduced nursing case management models that incorporated elements of both team and primary nursing within a context of controlled resources and shortened lengths of stay. The early case management models were structured on using hospital-based nurse case managers to monitor the patient’s progress toward discharge.
Carondelet’s model was initially designed as an acute care case management model. The job title “professional nurse case manager” described an RN with the minimum educational preparation of a bachelor’s degree. The case manager assumed responsibility for managing patients toward expected outcomes along a continuum of care. Carondelet collected data for the first four years after implementation of the model and found that quality and cost were improved. Job satisfaction increased for nurses, and their job stress decreased. In addition, patient satisfaction increased. Perhaps the most compelling finding was that some patients with chronic illnesses were not hospitalized. Those who were admitted had lower acuity levels. They were immediately linked to the healthcare system so that the length of stay at the beginning of the hospitalization was decreased. This resulted in lower costs for the hospital.
These findings resulted in the development of the first nursing HMO. The initial program, launched in 1989, focused on managing patients from a senior care HMO. The nurse case manager screened all patients admitted under the Senior Plan contract. The assessment included determining the necessary nursing services before discharge, monitoring of any community services being provided, and ensuring a continuation of care in the community, if necessary. Because the fees were capitated, the case manager could match the patient’s needs with the appropriate services.
New England Medical Center Hospitals in Boston used senior staff nurses to pilot the case manager role. The case managers carried a core group of patients for whom they provided direct patient care. They worked closely with physicians, social workers, utilization managers, and discharge planners. The core of the care delivery system was that outcomes should drive the care process. Several versions of critical pathways were developed for planning, managing, documenting, and evaluating patient care. During those early years, the tools of the trade moved more and more toward care management tools that structured the care process and outcomes, and were more interdisciplinary.
Both models were deemed successes by their organizations. Across the country, other hospitals began turning to these two role models for ideas, direction, and support. This was a watershed moment in healthcare delivery, as unprecedented numbers of healthcare organizations began to think about or implement case management. Its position in the healthcare arena was secured.
Although case management initially addressed the changes necessary for organizations to survive prospective payment, it was even more effective in its management of cases under a managed care system. In both reimbursement systems, patient care must be managed and controlled, with a tight rein on the use of resources, the length of stay, and continuing care needs.
The majority of the 1980s models did little in terms of changing the role functions of the other members of the healthcare team. Whereas nursing provided the driving force for the movement toward hospital-based case management, the other disciplines were slower in recognizing the value of such a system. Additionally, serious downsizing was only just beginning in the industry. Corporate America had already begun massive layoffs and downsizing initiatives. Thousands of people lost their jobs. Healthcare had not yet begun to feel the economic pinch as it was being felt in other businesses; the incentive for merging and downsizing departments was not yet there.
Shortly after these early models, case management began to mature as more hospitals began to implement case management models. One could see a direct correlation between the degree of managed care infiltration and the use of case management. In nursing case management, the nurse essentially functions as the leader of the team, similar to the team nursing approach. The difference was that the team did not consist of nurses only — the team was interdisciplinary, and each healthcare provider had a say in how a patient’s care would be delivered and monitored.
Shortly after this popularity of the nursing case management models, other disciplines caught on and began to pursue the design and implementation of case management systems. This increased buy-in from other disciplines resulted in a spread of these models throughout the country, leading to the birth of interdisciplinary approaches; hence, dropping “nursing” from the label to better reflect the models because they no longer were nursing in nature. Today, case management departments most commonly report to the chief operations or medical officers of an organization rather than to nursing services. This shift in reporting structure has resulted in giving case management departments more credence and power in an organization.
Summary
Case management began as a community-based model, but gained most of its popularity and appreciation after it moved into hospitals. It remained in hospitals for 30 years, and now is returning to its roots in the community, having gone full circle. The difference today is that we must develop strategies for linking case managers and case management models across the continuum so that case managers can work together from a patient perspective rather than a delivery setting perspective. That is the challenge and the opportunity before us today.
This month, we will review case management’s long and rich history from a community-based model to an acute care model and beyond.
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