Exploring nurse case manager practice

Author(s):Anne Llewellyn, MS, BHSA, RN-BC, CCM, CRRN

As healthcare delivery evolves, the case manager role expands.

Takeaways:

  • Case management is seen as a solution to lack of access to healthcare and limited resources.
  • Case management is a collaborative process of assessing, planning, facilitating, coordinating, evaluating, and advocating for options and services to meet individual and family healthcare needs.
  • Nurse case managers are viewed by providers and payers as key influencers on behalf of risk because of complex medical and behavioral health issues.

ACCORDING to surveys conducted by the Healthcare Access and Quality Index and the World Health Organization, the United States ranks consistently lower than other countries in many health outcomes measures. Quality and cost gaps are increasing in many key areas, and lack of access to services and resources limits the ability to use traditional healthcare delivery and payer systems. Case management is seen as a solution to address these issues.

The Case Management Society of America (CMSA) defines case management as a collaborative process of assessing, planning, facilitating, coordinating, evaluating, and advocating for options and services to meet an individual’s and family’s comprehensive health needs and promoting patient safety, care quality, and cost-effective outcomes. Case management offers a variety of career opportunities for nurses.

What case managers do

As political and healthcare leaders struggle to address healthcare challenges, nurse case managers work to:

• improve care delivery within a broad healthcare system
• collaborate with the healthcare team to identify, address, and break down barriers that interfere in care progression and negatively affect outcomes
• coordinate care and safe transitions to appropriate, cost-effective levels of care
• develop patient-centric care plans to meet individual and family need
• proactively follow up with and re-evaluate individuals and families to ensure the care plan’s effectiveness
• educate and empower individuals and families about diseases, health conditions, and needed care measures to reduce unnecessary complications
• gain patient buy-in and locate resources to meet individual and family needs.

Nursing opportunities

Case management is a multidisciplinary practice, but according to a 2018 Case Management Salary & Trends Survey, most case managers are nurses. Nurses are well suited to this role because case management functions closely follow the nursing process—assess, plan, implement, and evaluate. Case management broadens this framework and incorporates additional components, such as identifying and screening individuals at risk for medical, behavioral, and social issues and ensuring access to safe, quality, cost-effective healthcare services at the right time in the least restrictive setting.

As case managers, nurses have an opportunity to move beyond the bedside and influence care decisions to ensure they meet individual patient needs. Nurses work with the healthcare team to recognize challenges, create plans to overcome barriers, offer resources and tools, and advocate for patients and families. They also educate and empower patients to be active participants in their own healthcare, and they take a holistic view that encompasses behavioral challenges that impact individual patient health.

Nurse case managers are viewed by providers and payers as key influencers on behalf of those at risk as a result of complex medical and behavioral health issues. They work closely with patients and the healthcare team to improve care coordination and to identify resources to meet individual patients needs’ as they transition across the care continuum. As the United States moves to a healthcare system where providers and organizations are reimbursed for quality (value) versus quantity, nurse case managers are viewed as indispensable members of the healthcare team. They seek increased quality and value of care in every sector of the healthcare system, and as healthcare transitions to providing more care outside of traditional-based settings, case management will follow. (See Fast facts.)

Becoming a nurse case manager

Breaking into the case management field can be challenging. Few formal training programs currently exist, although as the practice matures, schools are adding case management as a focus for master’s of nursing programs. If you choose to pursue the career through formal education, look for programs taught by case

management leaders. However, also keep in mind that most nurses learn on the job. National organizations such as CMSA and the American Nurses Association provide networking opportunities for nurses to learn more about case management at the local and national level.

Case management standards of practice, developed by CMSA, guide those entering the field, helping them learn about the role, function, and scope of practice. National certifications are available and provide nurses an opportunity to demonstrate their competence to employers, patients and families, and the healthcare profession. (See Resources.)

Resources

Tap into these resources to learn more about healthcare in the United States, including how it stacks up against other countries, and the role of case management.

Case Management Society of America
• Standards of Practice for Case Management. 2016. miccsi.org/wp-content/uploads/2017/03/CMSA-Standards-2016.pdf
• The practice of hospital case management: A white paper. 2019. pathlms.com/cmsa/courses/12360

2018 Case Management Salary & Trends Special Report

The 2018 Special Report: Stepping Up to Certification: The Case Manager’s Guide to Certification 

Peterson-Kaiser Health System Tracker
• Sawyer B, McDermott D. How does the quality of the U.S. healthcare system compare to other countries? March 28, 2019. healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries

Centers for Medicare & Medicaid Services
• National health expenditure data. cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/index.html

Moving beyond the bedside

Case management is a fulfilling career for nurses who want to maintain patient contact as they move beyond bedside care. It offers opportunities to work as a patient and family advocate and positively influence care outcomes.

Please see below to read stories rom two nurse case managers. 

Anne Llewellyn is an independent nurse advocate in Plantation, Florida.

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