This paper looks at what constitutes case management, how it developed historically, the roles of nurses in case management, and the advantages and disadvantages of case management. It also looks at the future of nurse case managers, and how they will be affected by future directions in healthcare funding.
Case management in nursing is a process of coordinating health care interventions across levels of care to achieve measurable cost and quality outcomes (Zander, 2002). The Case Management Society of America defines case management as, ôa collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individualÆs health needs through communication and available resources to promote quality cost-effective outcomesö (Kuntz, 1999). Case management is performed by nurses in a variety of settings and produces a balance between the demands of quality health care and the patient and/or organizationÆs costs and resources (Zander, 2002).
Case management was developed in the early 1900s by social workers and public health nurses who identified needs and procured resources for their patients (Zander, 2002, 59). Payers began to use case management by nurses in the 1960s to oversee medical necessities for critically ill patients. This role was eventually provided by acute care hospitals, calling it ôutilization review,ö as a way to deal with payers. Case management under this system was usually provided by nurses who were no longer involved in direct patient care, or those who wanted weekday jobs with regular hours. With the onset of Medicare and Medicaid reimbursement using diagnostic-related groupings in the mid-1980s, health care providers began to manage length of stay, physician practice patterns, rehabilitation, and outpatient services, as reimbursement rules were tightened. Discharge planning became a legally mandated function for hospitals to participat...