1. Carter, Jolynne "Jo BSN, RN, CCM"

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With healthcare reform once again the topic of national debate, case management leaders must be part of the dialogue around how to improve quality, effectiveness, and cost-efficiency of care in the United States. In order for our voices to be heard, however, the case management practice needs to have more data and analyses that back what we all believe: That case managers delivering services to individuals can make a measurable difference in outcomes such as quality, costs-savings, and satisfaction.


Although research-based studies in case management have been done, more needs to be undertaken to evaluate the effectiveness of interventions across the healthcare spectrum. Case managers in every setting must target what is being measured to truly demonstrate the impact of interventions. As models of care delivery are developed, piloted, and evaluated, it will not be enough to say that case managers make a difference. We cannot point to anecdotal evidence, such as how we promote autonomy, patient education and self-care, adherence to physicians' orders, and informed decision-making, nor is it enough to tout the value that we provide as advocates for clients, as well as stewards of care resources, as individuals and families navigate complex, fragmented, and confusing delivery systems. In order for case management to be recognized as an integral part of care delivery models of the future, case managers need to have data and proven tools that demonstrate the effectiveness of our practice.


As case management leaders prepare to participate in the national debate around healthcare, we also need to recognize a difficult reality regarding some perceptions of case management. The Journal of the American Medical Association (JAMA) recently published results of 15 randomized trials on the effects of care coordination on hospitalization rates, quality of care, and cost among Medicare beneficiaries. The JAMA report showed that care coordination programs that did not have a strong transitional care component are unlikely to result in net Medicare savings. Those programs that provide substantial in-person contact to moderate or severe patients can be cost-neutral and improve some aspects of care (Peikes, Chen, Schore, & Brown, 2009).


These findings are hardly a strong endorsement of case management. Yet there are lessons to be learned from the Medicare demonstration projects. One is that case management had a positive impact when services were delivered face-to-face and not just telephonically. The other is that coordination among the physician, the case manager, and the patient was a key factor. Now, taking these findings into account, case management practice needs to integrate these evidence-based findings to the development and modification or improvement of care coordination and case management models that will positively influence healthcare delivery in meaningful-and measurable-ways.


Case management practice is already taking up this challenge. At the Collaborative Practice Summit hosted by the Case Management Society of America earlier this year, new developments in healthcare were discussed, with informative sessions on innovative care coordination and transition models and the role of technology in healthcare delivery. As practicing case managers and members of the executive committee of the Commission for Case Manager Certification (CCMC), Vivian Campagna, the CCMC's outgoing chair, and I were struck by the array of models and approaches that were being developed for various populations, from Medicare beneficiaries to employee groups.


Events such as the Collaborative Practice Summit support the necessity of continually expanding our knowledge and promoting evidence-based practice. There needs to be further research in the field to document the impact of case management on care delivery and to measure outcomes. The CCMC is committed to promote and participate in research in the case management field, with projects that can, for example, quantify the role of certified case managers.


As case managers explore ways to become involved in emerging models and programs, we must be aware of new terminologies and alternative labels. For example, when examining positions such as health coach, transition coach, and care coordinator, we can see that the essential functions are analogous to roles and duties of case managers. Across the spectrum of populations served, case management is a core component of what is needed to improve healthcare quality overall, while reducing costs.


Regardless of professional background or area of specialization, or the venue in which we practice, case managers do make a difference in the delivery of the right care and treatment at the right time. Now, we have to translate what we believe and know to be true into data and outcomes that are measurable and sustainable.


This is a call, not only to leadership in the practice but also to all case managers in every setting to examine what they are doing that is effective as well as what is not effective. If case managers are providing services to people who are not changing their health behaviors, then this becomes a challenge to the practitioners, who must ask themselves: What can they do differently to effect a change? How can we modify our behaviors as practitioners who are a part of continuous quality improvement?


The field must also address how case management can contribute solutions to the challenges being faced by healthcare today, such as an aging population with increasing incidence of chronic disease and multiple health problems. The current economic environment has also impacted people's ability to manage their health, leading many to refrain from filling prescriptions, to buy cheaper and less nutritional food, and to drop gym memberships. Job losses translate into more people without healthcare coverage, and many cannot afford Consolidated Omnibus Budget Reconciliation Act (COBRA). Without health insurance, routine visits and diagnostic tests are being skipped, increasing the possibility of a health crisis later on. All of these make the system less efficient and more costly for all payers, including the government, under Medicare and Medicaid.


As these factors come together in the debate around healthcare reform, case management needs to be part of the discussion. Our convictions and our anecdotal information alone will not earn us a place in the debate. By our willingness to examine our own practices, quantify our impact (through valid studies focusing on demonstrable results), and improve our outcomes, case managers will become valued participants at the discussion table to shape healthcare policies and systems to deliver care more effectively, efficiently, and with greater satisfaction.




Peikes, D., Chen, A., Schore, J., & Brown, R. (2009). Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. The Journal of the American Medical Association, 301(6), 603-618. [Context Link]