Case Management Scope of Practice

                The global community and the health care challenges arise from its rapidly changing health demands must have a dynamic agent (the Nurse Case Manager) who can provide care beyond borders. Case Management Nurse Scope of practice broadens its service to all health care settings by building networks, making health care more accessible to reach clients across the health-illness continuum for all walks of life. The care beyond borders is care that never stops.

            The three major contexts of Case Management are efficient timely care coordination, financial management appropriation, and proper utilization of medical resources to generate client-centered, safe, and cost containment outcomes in the least restrictive environment. It is a logistics process bridging the gaps in patient care as they enter through the healthcare system.

            The Case Manager who steers the multi-disciplinary process by following evidence-based standards and guideline criteria in patient coordination and care integration connecting hospital-based and community-based medicine in improving the flow of the healthcare system. Case Manager who acts as a concierge, advocates, navigators, and liaison works one-on-one with the clients and their families bringing the health care facility more accessible with seamless care facilitation.

The following is a representative list of case management practice settings according to the Case Management Society of America (2016):

• Integrated hospital care delivery system
• Skilled nursing and rehabilitation facility
• Long-term acute/chronic care facility
• Ambulatory care clinics.
• Community health institutions and primary healthcare centers
• University and School health care
• Corporations and companies
• Public health insurance and benefit programs such as Medicare, Medicaid, and state-funded programs
• Non-governmental organizations and charitable health institutions
• Private health insurance programs such as workers’ compensation, occupational health, catastrophic and disability management, liability, casualty, automotive, accident and health long-term care insurance, group health insurance, and managed care organizations
• Independent and private case management companies
• Government-sponsored programs such as correctional facilities, military health, Veterans Administration, and public health
• Mental/behavioral health facilities
• Geriatric services; including residential, senior centers, assisted living facilities and continuing care retirement communities
• Long-term care services; including home, skilled, custodial, and community-based programs
• End-of-Life, hospice, palliative, and respite care programs
• Physician and medical group practices
• Life care planning programs
• Population health, wellness and prevention programs, disease, and chronic care management companies

The Case Management Institute (CMI, 2019), elaborated the Case Management Scope of Practice in various health settings which categorized according to roles assumed by the Nurse Case Manager. The case management practice in pre-acute settings like physician’s office and clinics geared toward prevention through wellness programs, screenings, health risk assessments, risk-reduction strategies, telephonic triage (telephonic case management), disease management, facilitate access to healthcare services, community health referrals, coordination of medical and social services, and ensures patient knowledge and compliance with treatment. In a hospital set-up, the case manager is responsible for utilization review, discharge planning, resource management, multidisciplinary care coordination, and post-acute care transition. Acute Inpatient Rehabilitation case manager coordinates interdisciplinary meetings, verify benefits including authorization of services, facilitate referrals, formulate discharge planning, and utilization reviews.

The case manager in palliative care, home care, and hospice institutions include the roles of the caregiver and social worker in their case management works such as liaison officer, communicate with in-house physicians, client and family education, and assess for additional services and DME or durable medical equipment needed by the client. Insurance companies hired a case manager to act as a liaison officer between healthcare providers and insurance companies, care coordination, ensure care appropriateness setting, negotiate for services, monitor treatment compliance, health care benefit education, utilization management, and discharge planning. Case management on worker’s compensation focused on vocational activities, working with the employer to get the employee back to work such as communication between employer, claims adjuster, company’s legal and human resource departments, union representative and administrative agency, coordination of care between multiple healthcare providers, monitor health progress, utilization review, obtain health certification, perform job analysis, and accompany injured workers during health follow up appointments.

Nurse Case Managers as the frontliners of the healthcare delivery system are usually involved in the care of the clients over an entire episode of wellness and illness/disability continuum for the need of health services. The case management process focused on the holistic needs of the clients and its support system, which has a great impact affecting the delivery and the continuity of care. The case manager prioritizes the health care needs of the clients according to their current situational status by taking into consideration the following factors such as medical, physical, emotional, psychosocial, behavioral, mental, spiritual, beliefs, religion, and financial or possible sources of health funds.

In the study conducted by Tahan, H. & Campagna, V. (2010), it was forecasted that case management practice might evolve into a larger degree in the next few years following globalized health consumers as a sequel of intertwined upshots from the advent of technology and universal awareness. Moreover, the study illustrated the current practice of case management in a diverse setting which comprises of essential activities and knowledge areas that are compulsory for efficient and competent performance of case managers. Thus, the study suggested the reformation efforts of the health education system and health care administrations in developing education curricula, training, and certification for the advancement of case managers and its safe practice.

Amidst the dilemma facing by the healthcare system nowadays concerning the nursing exodus for bedside care, a new line of managers arise as the Case Manager. Nurses are in demand for opportunities in case management as the new breed of hospital leaders. Nurses are moving out from conventional roles outside the four-cornered patient’s room exploring and innovating care beyond borders.

References:

• Case Management Society of America. (2016). Standards of Practice for Case Management. Arkansas: CMSA.org.
• Tahan, H. and Campagna, V. (2010). Case Management Roles and Functions Across Various Settings and Professional Disciplines. Professional Case Management: The Official Journal of the Case Management Society of America, 15(5), 245-277.
• Case Management Institute. (2019). Roles and Functions of Case Managers in Various Settings. Case Management Study Guide. Retrieved on 16 August 2019 from roles and functions of case managers in various settings