Case Management in Community Health Nursing

I.    Origins of Case Management

Formally used by administrators in many public and social programs — Children’s Medical Services program (1935 Social Security Act), military servicemen returning from World War II, the elderly persons or persons with a mental illness who were at risk of placement in long-term care facilities.

1960s:    “Program coordinator”, programs designed to overcome the barriers of fragmented, duplicated and uncoordinated services

1970s:    “Case Manager”, social welfare & social workers.

1980s:    PPS (DRGs), capitation (managed care: HMOs, SHMOs), case management is a process design to allocate services appropriately and organize them efficiently.

From “finance oriented” system of care to “client-oriented” system of care

II.    Case Managers as Health Arena Guides
(Common Problems in obtaining access to care)

III.    Definitions and Conceptual Models of Case Management
A matter of matching and coordinating services, an entire continuum of services from a referral network to supervised planning and provision of direct nursing services

Case management in community nursing is operationally defined as a systemic process of assessment; service coordination, referral, monitoring and evaluation through which the unique needs of clients are met (Hopital Authority, 1995).

Case management for long-term care is based on three tenets:
1)    It is a holistic approach to the client
2)    It is a problem-solving strategy for the client.
3)    It is a dynamic process involving the interactions among the case manager, the client and the providers of care (including the family and other informal supporters, formal agencies, and physicians)

A conceptual –operational continuum (Beardshaw & Towell, 1990)
The brokerage framework, social entrepreneurship framework, key-worker/care coordinator function framework
 

IV.    Roles and Responsibilities of Case Management
Goal: to develop ways to provide cost-effective, high quality, comprehensive health services for clients across a continuum of care.

The responsibilities of the case manager are to assess, monitor, mutually plan and activate interventions, and coordinate and evaluate health care services to respond to the individualized needs of the patients and their families (Ethridge & Lamb, 1989; Gibson, Martin, Johnson, Blue, & Miller, 1994)

Roles of the case manager: manager, clinician, consultant, educator and researcher (Meisler & Midyette, 1994)

Service coordination and monitoring

Fundamental request: passionate about the care of a particular patient population; being knowledgeable of the resources available; possessing the ability to match resources and patient needs; work independently and be respected by other health care professionals

V.    Case Management Process
Assessment and collection of data
Organization of data and planning
Service planning and resource identification
Counseling, education and advocacy
Coordination and referral
Implementation and linkage of patient to needed services
Reassessment and monitoring

Case variables and most common diagnosis

VI.    Types of Case Management

The hospital-based model, hospital-to-community model, community-based model

VII.    Effectiveness of Case Management
Block Nurse Program in Portland, Oregon, USA (Bremer, 1989)
Case management activities: referral, planning, and advocacy
CHNs are uniquely qualified to conduct assessment and management activities that bridge the heath and social needs of the population.

CHNs should be well trained in assessment and treatment activities associated with geriatric health status, and counseling skills

Nursing Network at Carondelet St. Mary’s Hospital: including 1) acute care in-patient services, 2) extended care/long-term care services, 3) home care services, 4) hospice services, and 5) ambulatory care services.
 

VIII.    Case Management in Taiwan & Other Countries
Randomised trial of impact of model of integrated care and case management (Bernabei et al., 1998):
    Responsibility for management of care of elderly people living in the community is poorly defined
    Integration of medical and social services together with care management programmes would improve such care in the community
    In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced costs

International experiments in integrated care for the elderly (Johri, et al., 2003):
    Report available results on rates of hospitalisation, long term care institutionalisation, utilization and costs, impact on process of care, and health outcomes.
    The following common features of an effective integrated system of care were identified: a single entry point system; case management, geriatric assessment and a multidisciplinary team; and use of financial incentives to promote downward substitution.
    Community-based care can impact favourably on rates of institutionalisation and costs.
    Comprehensive approaches to program restructuring are necessary, as cost-effectiveness depends on characteristics of the system of care.
    Expansion of successful programmes to achieve widespread use remains a critical challenge.