Case Management in the Healthcare Industry

National Case Management Week is recognized from October 9-15. This year’s theme is “Caring – It’s What We Do.” In light of that, it seems like a good time to revisit the importance of case management in the healthcare industry. 

In the contemporary healthcare environment, case management can mean many things. The complexities of the various relationships between patients and caregivers, hospital billing departments and payers, and any other permutation thereof can drive the daily functioning of a case manager.  

One of the hospital’s more critical and complex departments is the Case (Care) Management Department. Much of the reimbursement documentation, length of stay, collaborative efforts among caregivers, and other vital functions related to inpatient processes lie in the domain of the Case Management Department. 

The American Case Management Association (ACMA) and the Commission for Case Management Certification (CCMC) have aligned on and approved a standard definition of case management: 

Case Management is a dynamic process that assesses, plans, implements, coordinates, monitors, and evaluates to improve outcomes, experiences, and value. The practice of case management is professional and collaborative, occurring in a variety of settings where medical care, mental health care, and social supports are delivered. Services are facilitated by diverse disciplines in conjunction with the care recipient and their support system. In pursuit of health equity, priorities include identifying needs, ensuring appropriate access to resources/services, addressing social determinants of health and facilitating safe care transitions. Professional case managers help navigate complex systems to achieve mutual goals, advocate for those they serve, and recognize personal dignity, autonomy, and the right to self-determination. 

The Case Management Society of America (CMSA) has defined Case Management as: 

A collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes. 

Both definitions are aligned in that case management is a process in which priority is put on patients in order to improve outcomes. Addressing inequities in access to care is essential to adequately enhance a patient’s well-being. Ultimately, the case manager can be a positive force for good in-patient care, advocating for needed services, coordinating care, ensuring care continuity, and helping manage financial and reimbursement needs. 

  A well-rounded approach to case management will ultimately benefit the patient in various ways. An experienced case manager includes strategies to address barriers and disparities in all aspects of their work. Incorporating these skills will promote better care coordination and access to resources while improving patients’ ability to cope. With these objectives in mind, case management will continue to have a significant role in meeting the needs of patients. 

 Tremendous benefits result from a well-functioning Case Management program. Length of stay reduces, patient satisfaction increases, unnecessary resource utilization is reduced, re-admission rates decline, and revenue increases result. As the case manager ensures that a patient’s interaction with the healthcare provider is medically necessary, they also work as a go-between with insurance companies, often advocating on the patient’s behalf. In some cases, their work convinces insurers to reverse coverage declines, improving a patient’s care and experience and helping providers avoid thousands of dollars in lost reimbursements. 

 Building a robust case management process for healthcare providers is vital to successfully navigate the ever-changing industry. Hospital case managers need to be valued for their understanding of healthcare delivery and their ability to combine quality, efficiency, and resource management in the delivery of patient care. The need for an effective and responsive case management department has never been greater. 

 In a nutshell, when a case management system works, everybody wins! We at Strata Health are dedicated to providing technology solutions to support case managers in operating at the top of their license while putting automation in place to handle some of those administrative functions that can fill their days. Giving time back to focus on caring as it is what case managers do!