Learning Objectives
By the end of this section, you will be able to:
- Describe four evidenced-based case management service models
- Discuss the role of the nurse as case manager
- Explain how virtual health care is useful in coordination of care
Case management developed as a way to coordinate and manage the care of clients with increasingly complex health-care needs, and it has evolved over the decades as a response to an increasingly complex health-care system (American Case Management Association, n.d.-b). The practice brings together health-care workers from different disciplines to provide coordinated, comprehensive, and client-centered care. It aims to address the physical, psychological, social, and environmental needs of clients and improve the quality of care while simultaneously reducing health-care costs and improving outcomes.
Case Management Service Models
The collaborative and organized approach to client care that involves assessing, planning, coordinating, and monitoring services and resources to meet the needs of individuals or groups, often in complex or challenging situations is called case management (American Case Management Association, n.d.-a). It is a multifaceted process that provides health care, mental health support, and social assistance across multiple disciplines and settings.
Case management aims to promote health equity by prioritizing needs, ensuring access to appropriate resources and services, addressing social determinants of health, and facilitating safe care transitions. Professional case managers develop plans to help each client move smoothly through the health-care system. They are instrumental in navigating complex systems to achieve shared goals; advocating for their clients; and upholding their personal dignity, autonomy, and right to self-determination.
The practice of case management is not a new one; it encompasses a range of strategies and services that have evolved over decades. The case management system originally evolved in the early 1900s to assist institutionalized people with severe and persistent mental illness (Kersbergen, 1996). A deinstitutionalization movement occurred in the 1950s and 1960s, leading to significant changes in mental health-care delivery as clients were diverted into community-based services (Smith et al.,1993). This resulted in a major increase in psychiatric hospital discharges and an increasing demand for community assistance. People with major needs and requirements found it challenging to navigate complex, community-based care systems and obtain psychiatric services.
Through the years, case management began to encompass the medical needs of clients in addition to the psychiatric ones. The introduction of Medicaid and Medicare in 1965 created two vast new government health-care programs that needed navigating. Health care has only continued to grow more complex in the decades since, due to new laws, technology, and cultural changes. Different models of case management have evolved along with these changes in order to address the specific needs of different communities.
The Brokerage Case Management Model
In the brokerage case management model, a case manager acts as a “broker” or intermediary between a client and the various services and resources that the client needs (Substance Abuse and Mental Health Services of America [SAMHSA], 2021a). This case manager is typically a social worker or nurse. The case manager helps the client to identify their needs, access appropriate services, and coordinate care among multiple providers.
In this model, the case manager is responsible for assessing the client’s needs, developing a care plan, identifying appropriate service providers, providing referrals, and coordinating care among the different providers. The case manager may also provide ongoing monitoring and support to ensure that the client’s needs are being met and that services are delivered effectively. Interactions between the case manager and client tend to be relatively brief, so the brokerage model is better suited to clients with minimal needs.
The Clinical Case Management Model
In the clinical case management model, one of the client’s clinicians, such as a nurse or therapist, serves as case manager (SAMHSA, 2021a). Because the case manager is also the client’s clinician, they are more closely involved with individual clients than in the brokerage model. With a closer knowledge of their clients’ care plans, wants, and needs, clinical case managers are able to focus on executing the entire care plan for each client.
Clinical case managers can encourage clients to interact with their family, friends, and peers while also assisting them in overcoming social, emotional, and mental barriers to services. An additional benefit of this model includes increased one-on-one time between the case manager and client, which, when the case manager is a nurse, strengthens the nurse-client relationship and helps clients feel motivated and supported. Due to the intense, comprehensive nature of the relationship with each client, however, clinical case managers see fewer clients.
The Intensive Case Management Model
The intensive case management model (ICM) is intended for severely mentally ill clients. The purpose of the ICM is to provide high-quality, coordinated care to individuals with complex health and social needs in a short amount of time (Ponka et al., 2020). Individuals who may benefit from the ICM model are typically those with multiple chronic conditions, complex medical and social needs, and high utilization of health care. These individuals often require intensive and ongoing care coordination and support to manage their conditions effectively.
Under an intensive case management model, the client receives much more individual attention from the case manager than in other models, ideally resulting in a stronger relationship between the case manager and the client. This strong relationship, along with the higher degree of the case manager’s involvement with the client, results in faster, more thorough results and gives clients with severe mental illness the resources and support they need to live independently, manage their symptoms, and improve their quality of life.
ICM does have its drawbacks. As with the clinical case management model, the ICM is resource-intensive. Each case manager carries a relatively small caseload. It is also time- and cost-consuming.
The Strengths-Based Case Management Model
The strengths-based case management model (SBCM) developed in response to concerns that case management models were focusing mainly on clients’ limitations and impairments. In contrast, the SBCM model aims to build on the strengths and abilities of individuals with mental illness (SAMHSA, 2021a). By recognizing and utilizing each individual’s unique strengths and skills, case managers promote recovery and improve outcomes more effectively.
The SBCM model is challenging because it requires a highly personalized plan for each client, with an eye on cultural sensitivity. With its focus on positivity, there is a possibility of overlooking serious issues or challenges. It has numerous benefits, however, including the following:
- Individualized and person-centered: The SBCM model is tailored to the needs and preferences of each client. The approach recognizes that every person has their own unique strengths and challenges and works to identify and build on those strengths to achieve recovery goals.
- Collaborative and empowering: In the SBCM model, the person with mental illness is an active participant in their own care. The approach empowers individuals to take an active role in their recovery process, working in partnership with their care team to set goals and make decisions about their treatment.
- Holistic and comprehensive: The SBCM model recognizes that mental health is influenced by a wide range of factors, including social, economic, and environmental ones. The approach addresses not only the individual’s mental health symptoms but also their broader health and social needs.
- Strengths-focused and solution-oriented: The SBCM model focuses on identifying and building on the individual’s strengths and abilities, rather than highlighting their weaknesses. The approach also emphasizes finding solutions to problems rather than simply identifying them.
- Outcome-driven and evidence-based: The SBCM model focuses on achieving measurable improvements to the individual’s mental health and overall well-being. The approach is grounded in scientific research and has been proven to be effective at improving outcomes for individuals with mental illness.
Figure 7.2 shows the degree of closeness between the client and the case manager in each of the service models.
The Nurse’s Role as a Case Manager
Case management is a practice used by and including many disciplines. Because the discipline of nursing focuses on the whole person, however, nursing is the predominant field practicing case management. Nurses play a critical role in care for clients, serving as both care providers and care coordinators. Consequently, the role of case manager often falls to the nurse.
Nurses often have extensive clinical experience and knowledge of the health-care system, which makes them well-suited for this role. Additionally, nurses are often involved in the care of clients from admission to discharge, which allows them to have a comprehensive understanding of the client’s needs, preferences, and goals. Furthermore, nurses are trained to coordinate care across multiple disciplines and to communicate effectively with clients, families, and other health-care providers. This makes them valuable members of a care team and capable of overseeing the coordination of care for clients with complex mental and other health conditions.
Virtual Health and Care Coordination
Virtual health and care coordination are two interrelated concepts that are increasingly important in modern health care. Nursing plays a central role. Virtual health, or telehealth, is the application of electronic information and communication technologies to facilitate remote clinical health care, education for both clients and health-care professionals, and activities related to public health and health-care administration (SAMHSA, 2021b). Telehealth utilizes digital technologies, such as telemedicine, remote monitoring, and mobile health apps to deliver health-care services and information remotely. This can help to improve access to care, reduce costs, and provide more personalized and convenient care for clients. Telehealth can also enable better care coordination by allowing health-care providers to share information and collaborate more easily (Mechanic et al., 2022).
The organization and distribution of health-care services across different providers and settings in order to ensure that clients receive the right care at the right time is called care coordination. This can involve coordinating appointments, tests, and treatments, as well as managing transitions between different health-care settings, such as hospitals, primary care clinics, and home care. Care coordination is important for ensuring that clients receive high-quality care and avoid unnecessary complications and hospitalizations.
Telehealth and care coordination are closely linked because telehealth technologies truly facilitate care coordination. For example, virtual visits can enable primary care providers and specialists to consult with each other and coordinate care for clients with complex conditions. Remote monitoring technologies can also help to ensure that clients receive appropriate follow-up care after a hospitalization or procedure, and mobile health apps can provide clients with personalized information and support to help them manage their health and navigate the health-care system.