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Case Management in Health Care
The Case Management Society of America defines case management as:
- "a collaborative process of assessment, care 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."
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
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.
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. 
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.
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. 
- Case report
- Case presentation
- Discharge planning
- Cost containment
- Health care administration
- Health care costs
- Health care delivery
- Health insurance
- Health service needs
- Intake interview
- Long term care
- Managed care
- Needs assessment
- Nursing process
- Outreach programs
- Social casework
- Treatment duration
- Treatment planning
- Utilization review
- Medical case management
References & Bibliography
- ↑ Case Management Society of America. Definition of Case Management. URL accessed on 2007-01-13.
- ↑ 2.0 2.1 2.2 William F. Bluhm, "Group Insurance: Fourth Edition," Actex Publications, Inc., 2003 ISBN 1-56698-448-3
- ↑ 3.0 3.1 Peter R. Koongstvedt, "The Managed Health Care Handbook," Fourth Edition, Aspen Publishers, Inc., 2001 ISBN 0-8342-1726-0
- Harris,M. & Bergman,H. C. (Eds.), Case management for mentally ill patients: Theory and
practice.Chronic mental illness, Vol 1. Langhorne, PA, US: Harwood Academic Publishers/Gordon & Breach Science Publishers.
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of team-based intensive case management for patients with schizophrenia, Psychiatric Services, 46, 1263-6.
- Bigelow, D.A., Young, D.J. (1991). Effectiveness of a case management program. Community Mental Health Journal, 27, 115-23.
- Bond, G.R., Miller, L.D., Krumwied, R.D., & Ward, R.S. (1988). Assertive case management in
three CMHCs: a controlled study. Hospital and Community Psychiatry, 39, 411-418.
- Burns, R., Creed, F., Fahy, T., Thompson, S., Tyrer, P., White, I. (1999). Intensive versus
standard case management for severe psychotic illness: a randomised trial. The Lancet, 353, 2185-89.
- Byford, S., Fiander, M., Barber, J.A., Thompson, S.G., Burns, T., Van Horn, E. et al. (2000).
Cost-effectiveness of intensive v. standard case management for severe psychotic illness. UK700 case management trial. British Journal of Psychiatry, 176(JUN.), 537-543.
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Harris,H. C. Bergman, (Eds.), Case management for mentally ill patients: Theory and practice.Chronic mental illness, Vol 1. (pp. 217-235). Langhorne, PA, US: Harwood Academic Publishers/Gordon & Breach Science Publishers.
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rehospitalisation and utilisation of ambulatory care services. Hospital and Community Psychiatry, 43, 895-9.
- Curtis, J.L., Millman, E.J., Struening, E., D'Ercole, A. (1996). Deaths among former psychiatric
inpatients in an outreach case management program. Psychiatric Services, 47, 398-402.
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- Case Management Society of America
- On the Case from minoritynurse.com
- Case management associations at the Open Directory Project
- Resolve Case Management Software
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