Case Management

This is the sixth article in the Medical Management "Signature Series" by Managed Care Resources, Inc. -- articles on topics in managed care written by experts in the field. The authors of this article are Ira H. Rosenberg and  Mary Sajdak.

The term "case management" is frequently used when describing an approach for managing complex medical care. In 1992, the CIRSC defined case management as "... a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services to meet an individual's health care needs using community resources available to provide quality and cost-effective outcomes." This definition describes a complex, multidisciplinary process that requires the input and support from many players in the health care delivery system, including patients, their support system such as the family and friends, all care providers, and vendors and/or other suppliers to the health care system. All work in a coordinated way to achieve agreed upon goals for the patient.

Organizational Use of Case Management

Many different types of organizations use the case management approach:

  • Hospitals employ a case management process to manage the use of inpatient resources. Clinical pathways, which describe the services and activities appropriate for a diagnosis, are used to guide treatment during inpatient stays. The guidelines' design is consistent with "best practice". Practitioners use them to help manage the length of stay and service usage.

  • Managed care organizations (MCOs) use case management to coordinate complex medical care. Historically, MCOs focused on small patient populations with catastrophic conditions that consumed disproportionate health services dollars. This type of case management is known as large case management.

  • Worker's compensation carriers may use case management to organize the physical and vocational rehabilitation of a worker injured on the job. Efficient arrangement of medically necessary services promotes optimal patient outcomes. This approach can reduce the period of disability, and assure a high quality of care at an appropriate cost.

  • Community-based organizations use case management to establish client linkages to reimbursement programs, to increase access to medical, social, or vocational agencies in order to resolve issues of medical care, housing and employment. Case managers in these programs are usually more skilled at meeting the social needs of patients than their clinical needs. Providing transportation and assuring clients keep their appointments at the various agencies are important components of their activities. This type of case management is probably the most established of all. It has provided the foundation for other care providers to adopt their techniques.

Despite the different approaches of the various types of organizations to case management they similar in a number of ways:

  • All influence patient utilization vis-a-vis the type of services and systems of care.
  • All focus on the organization and sequence of services, plus the resources needed to respond to individual concerns.
  • All use the expertise of multiple professionals
  • All reflect the needs of the target populations

Managed Care Use of Case Management

Case management is attractive to managed care organizations because of its ability to respond uniquely to each individual, to arrange services with quality providers that are consistent with the benefit plan, and to contain costs. Properly done, case management can align the interests of the patient, the physician and the payor alike.

Today most MCOs focus their case management programs on the 3-5% of the population that consume an inordinate amount of resources. Originally, case management focused largely on patients with catastrophic illnesses or injuries. However, the emergence of the National Commission for Quality AssuranceA accreditation standards (NCQA), and the enrollment of Medicaid and Medicare populations in managed care plans, have encouraged MCOs to rethink their case management strategies. The use of case management for catastrophic illness or injury still occurs, but programs have begun to focus more intensely on conditions that are more prevalent in the population.

NCQA guidelines encourage MCOs to demonstrate their awareness of the health care needs of the population they serve, and to implement measures to improve health status. One way MCOs have done this is through the implementation of disease management programs for prevalent conditions. At the core of disease management is a plan that describes what health care professionals should do. For example, an asthma disease management guideline would include: visit frequency, medications, patient education content, methods to monitor treatment response, and frequency of contact by the case manager. In between visits to the health care provider, the case manager assesses patient compliance with the treatment plan, measures patient response, and assists with problem resolution.

The enrollment of Medicare and Medicaid populations has encouraged MCOs to develop the infrastructure and community linkages that are critical to serving these populations. Case management programs for these individuals focus on the impact of social and economic factors that interfere with a patient's ability to comply with the treatment plan, e.g., patients who may not be able to afford the transportation for doctor visits may wait until their condition has deteriorated to a point where an ER visit is required.

Medicare members may require special interventions, with activities focusing on services and approaches to avoid premature institutionalization. Linkages to community-based agencies to provide assistance with the activities of daily living and home-based medical care may be implemented to maintain the independence of the "frail" elderly.

Case Management Program Characteristics

A well-run case management program, is organized and staffed appropriately, has well developed policies and procedures, has an internal evaluation mechanism, and links appropriately to other departments such as provider relations, claims and member services.


In many MCOs the case management function is part of utilization management. If an MCO has dedicated case management staff, they may interact with staff performing precertification or concurrent review. Cases identified as potential case management are routed to the case manager for further assessment and possible case management implementation.

As the target population needing case management techniques increases, there may be opportunities for case managers to work with members of the quality staff or to interact with disease management work groups.

Registered nurses (RNs) frequently act as case managers, and traditionally have been preferred because of their clinical knowledge, their ability to think holistically, and their use of a scientific problem solving approach. Of course, the financial and organizational skills required of case managers must be obtained through other means, such as prior experience or special training. Social workers are also valuable as case managers, especially with patients who have socially or economically complex situations. Case managers with this type of background can also manage the medically complex with appropriate training.

The number of case managers required depends upon the composition of the MCO's membership. Medicare and Medicaid populations tend to require a lower ratio of case managers to members, a suggested ratio of 1 to 5,000 or 7,500. For commercial members the ratio is more likely to be 1 to 10,000.

While specializing in a particular area of case management is always possible, MCOs may be better served to encourage case managers to function as generalists, which will assist with case assignment and facilitate timely implementation.

Policies and Procedures

A well developed set of policies and procedures are necessary to guide the case manager in pre-determined courses of action. Examples include the following:

  • Case management identification process, e.g. multiple medications, functional deficit, multiple admissions
  • Case management assessment process
  • Guidelines for implementing case management to include type of case management intervention based upon assessment
  • Treatment plan design
  • Benefit plan extension process (e.g. extra-contractual benefits)
  • Attending physician, family and patient communication
  • Documentation requirements
  • Patient outcomes evaluation
  • Case management closure process
  • Patient and provider satisfaction
  • Interface and communication with other MCO departments

Internal Evaluation Mechanism

Evaluation of the case management program includes the ability to meet specific program goals, to prevent or delay additional morbidity in the target population and to keep service utilization within pre-determined parameters.

Active case management programs enable patients to maintain the highest level of wellness for the longest period. This means a slowdown in the progression of the disease, engaging the patient as an active participant in the disease management process and monitoring the disease trends in the patient population served.

For the case management population, it is expected that utilization experience will be better than that of similar populations. For example, the admissions or days per thousand experience of an MCO with a case management program for seniors should be lower than the national average.

In addition to the quantitative aspects of program performance, the satisfaction of the patients and the providers should be accounted for. If the program assists with keeping bed days within the appropriate target but alienates physicians and patients, then the program can hardly be successful over the long term.

Links to other departments

The success of the case management program depends on the ability of various MCO departments to communicate and support each other. For example, the provider relations department is key to communicating the benefits and advantages of the case management program to people in a position to assist the process. Without reinforcement from provider relations, it is unlikely that physician office staff will be able to identify patients who could benefit from more intensive intervention. Provider relations staff may also be able to discuss with network physicians how the use of case management may have improved patient outcomes and financial performance.

Another area of collaboration is in the claims area. If a member has been provided with extra-contractual benefits, the claims staff must be alerted so the claim is paid. Special prices or discounts that the case management staff has obtained should also be communicated to the claims staff to assure the appropriate payment of claims.

Finally, as customer services interfaces most frequently with MCO members, they need to be trained to recognize circumstances where case management might be appropriate. Especially in the elderly, a question or inquiry may be a disguised request for assistance.


The case management process provides an opportunity for the managed care organization, the physician and the case management staff to combine their expertise and resources to provide the most efficient, high quality care required to meet the members needs. The collaboration between these parties can produce quality patient outcomes.

Case management's potential is only beginning to be explored as MCOs continue to search for ways to contain cost while retaining quality. The expansion of case management through disease management is an example of the ability of MCOs to respond to the changing needs of the population served.

For more information on Managed Care and Case Management please contact us at (630) 325-6543 or by email at .

We hope that you will join us as we explore all of the elements of medical management in the coming months. In addition, we are offering a "Signature Series" on "Managed Care Contracting". We hope that the two series combined will lessen the mystery of managed care and help level the playing field between providers and payers.

Ira H. Rosenberg

Ira H. Rosenberg

President, Managed Care Resources, Inc.


Related World Wide Web Sites:

A. National Committee for Quality Assurance (NCQA)

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