Case management (US healthcare system)
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Case management is an area of practice within several healthcare professions. Most case managers are nurses or social workers.
The term case management is also used to refer to dispute resolution systems which provide court or tribunal officials with closer administrative control over the litigation process than is traditionally associated with common law litigation.[1]
Case management in health care
The Case Management Society of America defines case management as:
- "a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes."[2]
Most nurse case managers work in hospitals or at health maintenance organizations.
Case management focuses on delivering personalized services to patients to improve their care, and involves four steps:
- 1) Screening to find appropriate patients
- 2) Planning & delivery of care
- 3) Evaluation of results for each patient & adjustment of the care plan
- 4) Evaluation of overall program effectiveness & adjustment of the program[3]
In the context of a health insurer or health plan it is defined as:
A method of managing the provision of health care to members with high-cost medical conditions. The goal is to coordinate the care so as to both improve continuity and quality of care and lower costs.[4]
Specific types of case management programs include catastrophic or large claim management programs, maternity case management programs, and transitional care management programs.[3]
Case managment functions
Health insurer and HMO setting
Case managers working for health insurers and HMOs typically do the following:
- 1) Check benefits available;
- 2) Negotiate rates with providers who are not part of the plan's network;
- 3) Recommend coverage exceptions where appropriate;
- 4) Coordinate referrals to specialists;
- 5) Arrange for special services;
- 6) Coordinate insured services with any available community services; and
- 7) Coordinate claims with other benefit plans. [3]
By identifying patients with potentially catastrophic illnesses, contacting them and actively coordinating their care, plans can reduce expenses and improve the medical care they receive. Examples include identifying high-risk pregnancies in order to ensure appropriate pre-natal care and watching for dialysis claims to identify patients are risk of end-stage renal disease. The amount of involvement an insurer can have in managing high cost cases depends on the structure of the benefit plan. In a tightly managed plan case management may be integral to the benefits program. In less tightly managed plan, participation in a case management program is often voluntary for patients.[4]
Health care provider setting
Case managers working for health care providers typically do the following:
- 1) Verify coverage & benefits with the health insurers to ensure the provider is appropriately paid;
- 2) Coordinate the services associated with discharge or return home;
- 3) Provide patient education;
- 4) Provide post-care follow-up; and
- 5) Coordinate services with other health care providers. [3]
Employer setting
Case managers working for employers typically do the following:
- 1) Verify medical reasons for employee absences;
- 2) Follow up after absences from work due to poor health;
- 3) Provide health education;
- 4) Assist employees with chronic illnesses; and
- 5) Provide on-site wellness programs. [3]
Case Management and the regulation of mediation
Case management refers to systems in which court or tribunal officials assume closer administrative control over the litigation process than is traditionally associated with common law litigation. [1] The Assisted Dispute Resolution program was introduced into the Federal Court in 1990. This was instigated after a number of cases failed to reach resolutions after several directional hearings. The parties had still not isolated the issues requiring determination. Judges could then refer the parties to a court registrar for mediation. The following section was introduced into the Federal Court of Australia Act in 1991:
‘Subject to the Rules of Court, the Court may, with the consent of the parties to proceedings in the Court, by order refer the proceedings, or any part of them or any matter arising out of them to a mediator or an arbitrator for mediation or arbitration as the case may be….’ Mediation as an alternative dispute resolution (ADR) method is designed to avoid resorting to formal court-based adjudication and is now also being applied to criminal matters. Traditional theories of criminal justice view the matter as one between the offender and the state. [5]
It was not necessary to have the parties consent to the mediation process. The judge could direct the mediation. Case management was designed to identify and define issues in dispute and to reduce delays, costs and unnecessary pre-trial activities.
It is now becoming widely accepted and even institutionalised and promoted by governments, that ‘what was born of resistance and opposition to the formal justice system has been extensively integrated and co-opted into the system’. [6]
References
- ^ a b Boulle, L. (2005). Mediation: Principles Process Practice. 2nd Edition. Queensland, Australia. LexisNexis Butterworths.
- ^ Case Management Society of America. "Definition of Case Management". Retrieved 2007-01-13.
- ^ a b c d e William F. Bluhm, "Group Insurance: Fourth Edition," Actex Publications, Inc., 2003 ISBN 1-56698-448-3
- ^ a b Peter R. Koongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001 ISBN 0-8342-1726-0
- ^ Sarre, R. and Earle, K. (2004). Restorative Justice in Key Issues in Criminal Justice Sarre R, and Tomaino, J. (eds) Key Issues in Criminal Justice, Adelaide: Australian Humanities Press
- ^ Astor, H & Chinkin, C. M. (2nd Edition, 2002). Dispute Resolution in Australia. Sydney Australia.. LexisNexis Butterworths
See also
External links
