Case Management : An Effective Component Of Health And Behavioral Health Service Delivery

Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations

Case Managers have a challenging job, often dealing with patients, community agencies and facilitating their hospital discharge to the next level of care. They collaborate and communicate with the entire healthcare team and mostly with the patient during the hospitalization process. They act as support for all stakeholders to achieve positive patient outcomes. In this paper, I will be interviewing Ian Mopas, who is a Patient Care Coordinator at Kaiser Permanente in Redwood City about his education, work training, goals, and objectives as a Care Coordinator, and his responsibilities in his organization.

The Case Management program is offered by Kaiser Permanente to support members with complex medical, psychosocial, and care management essentials. This specialized service is provided by case managers. The case managers are either Registered Nurses who are certified in case management or qualified Social Workers. Case managers provide necessary information and education to promote understanding, reduce the chance of possible complications, and facilitate effective and proper delivery of care and services.

How does case management achieve efficiencies in the delivery of health care? How does case management differ from disease management?

The interview of a case manager is designed to give students the chance to create an opportunity of interaction with case management. During the interview, the focus is to establish connection in understanding the purpose of their duty, adapted theory of function, ability to maintain self-poise, intellectual thinking process to maneuver from one case load to another, and demand of the population to whom the service benefits. The interview process provides an overview adjustment to distinguish the relevance between the provider mission statement in contrast with the employee who transforms the vision to concrete, workable possibilities of wonders while helping the client. The reinforcement of speaking live with a case management employee helps to understand the purpose, the process of initiating help, and placing individuals with community resources to help support individual needs.

According to an article published in Case Management Advisor (2008), education assists case managers with being as knowledgeable as possible to identify and coordinate all the resources that their patients need and continued education is an ethical responsibility of a case manager. The article also suggests that advocacy is an ethical responsibility of a case manager. When advocacy is forgotten ethical issues occur. Fraser and Strang (2004) explain that case managers must be given the tools to allow them to function in their role with confidence and competence to act as strong advocates for their patients. Support for decision making is also a key component of case management. Coffman (2001) offers key points from The Code of Professional Conduct for Case Managers advising that case managers are guided by the principle of autonom. Case mangers achieve autonomy through advocacy. If case managers are expected to function with complete autonomy, then case managers require the assusrance that their leader ship will support them when difficult decisions have to be made, (Fraser and Strang, 2004). The concept of employer employees explains that by involving employees in developing the mission and values of the company, this allows employees feel empowered (Porter-O’Grady & Malloch, 2007). By allowing the case manager to be part of the development of the

In order to, differentiate between utilization management and case management using the seven case management standards, it is first important to define each individual component. To begin with, a key component of quality and cost effective care is Utilization Management (UM). Utilization management is a way to assure that the appropriate care is medically efficient, a suitable use of health care services, proper procedures, and is applicable with provisions aligned in the health benefits plan. Case Management engages quality services in a timely coordination of patients’ specific needs in an approach that promotes positive outcomes by means that are cost effective. Case management may be developed during a single health care setting that may then transition throughout the care continuum. The seven standards are key components that described to maximize benefits and minimize the opposition.

The case management process consists of five parts: assessment, treatment planning, linking, advocacy, and monitoring. It is not a linear process and does not follow the order it is written up. There may be some back and forth and returning to certain points.

Case management is a continuous balancing act of judgment calls, making ethical choices, getting along with coworkers, and following legal protocol. It is the duty of the case manager to know how to develop a relationship with both clients and coworkers while still maintain their professionalism. The healthcare professional must always leave their personal opinions at home and provide the same quality of care to all their clients regardless if they have different views, religion, sexual orientations, or cultures. The case manager needs to ensure that the client’s concerns will be put first no matter what, and should also clarify that the as the professional he or she will do all that is necessary to provide the best quality of care to their client.

Rothman, J., & Sager, J. (1998). Case Management: Integrating Individual and Community Practice (2nd ed.). Boston, MA: Allyn and Bacon.

Today almost every major health care organization has a case management program managing and directing the use of health care services for their clients. Also, case management by payer organization is recognized as external case management (Jacob & Cherry, 2007). Hospitals recognized the need for the case management model in the mid-1980s to manage the lengths of stay of hospitalized patients and the treatment plans (Jacob & Cherry, 2007).

What I understand of case management is that it helps Social Workers in helping their clients, meaning social workers take actions to manage the various aspects of cases they are working on. Case management is also a shared process of assessment, planning, facilitation and advocacy for decisions and services to meet an individual’s need through communication and available resources. Case management examines the person’s physical, emotional, environmental state, and promotes quality and cost-effective outcomes. In addition, in Case management the worker helps to empower the clients to become self-sufficient. Moreover, Case management is structure into six principles

in The ICM model, a Case Manager is responsible for the individual caseload, while the ACT approach has a multidisciplinary clinical team who share the responsibilities of the caseload. The other difference, is the ICM Case Manager helps the individual by connecting and coordinating service for them with other direct service providers. For example, the ICM offers the mental health counselling but may need to link the person to an outside agency for employment supports and another agency for housing supports. The ACT team generally puts the majority of their time providing clinical services to the individual in the community with very little assistance from other service providers. Both systems are person’s centred and our strength base.

As case managers review the patient’s achievement of the expected outcomes of care, they also can review the processes used to achieve these outcomes. Because case management links the three elements of structure, process, and outcome, case managers can serve an important function in assisting their organizations in the measurement of quality of care. Linking Structure and Process to Outcomes Case management has been described as a structure and process model, linking both to the outcomes of care. The patient’s stay most likely will be prolonged, quality care will not be provided as per the case management plan, the patient’s satisfaction with care will suffer, and reimbursement may be at risk. Typically, case managers use the clinical endpoints as indicators for when a patient has completed a particular stage in the care process and can be moved to the next level.

Case Management – Case management serves to monitor patient progress and compliance with recommended addiction treatment plans. Reports to outside parties such as courts, children’s protective services, licensing boards, and employers are provided as