Nurse Case Management: Roles, Settings, and Goals

Introduction to Nurse Case Management

The term case management has been used in community health settings for many years, but is relatively new to the acute care setting. As defined across hospitals, case management programs often bear little resemblance to one another. The term has been used to describe a wide variety of programs and services in the hospital setting, leaving many nurses and other healthcare professionals confused about how case management compares with nursing care delivery systems (Lyon, 1993).

The practice of case management depends a great deal on the type and structure of the particular organization. Although case managers come from many disciplines, most have a background in nursing or social work. Nurses are well matched to the role because the functions of case management closely follow the framework of the nursing process: assessment, planning, implementation, and evaluation. Case management as a process widens this framework and incorporates additional components, such as patient identification or case selection; resource identification; advocacy; coordination, monitoring, and evaluation of care; data collection and analysis; and documentation of multiple outcomes, including cost, quality, and client status (White and Hall, 2006).

The Nursing Process and Case Management Functions

Case management nursing duties include assessing and monitoring patients and determining eligibility for treatments. This is done by using clinical pathways to determine whether the plan of care being provided meets the patient's needs, and arranging for additional services as needed to help patients achieve desired outcomes. A case management nurse carries out research, analyzes data, and coordinates patient care with all members of the patient's healthcare team while providing each patient with individualized planning in order to ensure optimum outcomes, appropriate care, and cost-effective services (Case Management Nursing Career Profile, 2006).

Hospital-based, or acute care, case management is also referred to as episodic case management. This type of case management is applied to patients during a short-term episode of illness. This model places the staff nurse in the position of case manager. In addition to hands-on direct nursing care, these nurses are also responsible for indirect nursing functions that include physical assessments, medication administration, intravenous administration, wound management, and patient and family education (Cesta and Tahan, 2002).

Acute Care Case Management Roles

The goals of acute case management often include: encouraging timely discharges; prompt and efficient use of all available resources; achievement of expected outcomes; collaborative practice; coordination of care across the continuum; and performance improvement activities that lead to optimal patient outcomes (Cohen and Cesta, 2005).

A nurse case manager in the acute care setting can function in three distinct roles. The first is that of Utilization Review Manager. These case managers are responsible for reviewing charts to assess the use of interdependent hospital systems, the timeliness of service, and the safe and appropriate utilization of services. The utilization review manager works closely with the attending physician to monitor the quality of services provided. If a review of the patient's stay and service utilization indicates that acute care is no longer warranted, the utilization review manager nurse may request that outpatient or alternative services be arranged (Case Management, 2009).

The second role is that of Quality Manager. The quality manager or quality risk manager nurse is accountable for the overall quality of care being delivered. This nurse may also work within the risk management office, collaborating with the hospital's risk management team to address any legal issues that arise during a patient's hospital stay (Case Management, 2009).

The third role is that of Discharge Planner. A discharge planner coordinates all aspects of a patient's admission and discharge. This nurse evaluates high-risk patients — those with high-risk diagnoses such as stroke, myocardial infarction, or complicated pneumonia — and identifies the social and financial resources that such patients may need in order to develop a safe and workable discharge plan. The discharge planner draws on clinical experience and assessment skills, reviewing the patient's current course of illness, past medical history, and available family or community support outside the hospital (Case Management, 2009).

Conclusion

Overall, the goal of case management is to provide the best possible services and outcomes to the patients involved. Whether practiced in the acute care setting or the home care setting, the fundamental goals are essentially the same, though implementation strategies differ by context. In the acute care setting, the strategy focuses on reaching the point where acute care is no longer required, thereby controlling costs and reducing caseloads for acute care practitioners. If ongoing care is still needed, the patient can be transitioned to a home care setting — typically a longer-term environment that requires not only traditional nursing practices but a range of additional modalities as well.