Case management models

CCMC Glossary of Terms Related to Case Management Models

Nursing Case Management: A process model using the components of case management in the delivery aspects of nursing care. In nursing case management delivery systems, the role of the case manager is assumed by a registered professional nurse.

Overview of Case Management Models

Case management models can be divided into two categories those in the hospital setting and those outside the hospital setting. Those inside the hospital can be collaborative models, with the case management department made up of social workers, utilization reviewers and case managers each with their own distinct roles, or functional models integrating utilization review and discharge planning into one role. Most acute care case management programs incorporate multiple models to form one that works for their organization.

Acute Care Case Management

Integrated Functional Model- Created by integrating the utilization review and discharge planning activities into one role. 

Clinical Resource management models-The Case Manager follows the patient through acute care facilitating safe, timely, cost efficient care and transition to post acute care. 

Disease Management Model- Case Manager monitors the utilization of resources and coordinates post acute services for patients with certain high risk diseases such as asthma, diabetes, heart failure and renal failure. In addition, they promote education, social intervention and therapeutic compliance to manage these diseases post hospitalization and reduce readmissions. 

Outcomes Management Model- Uses evidence based protocols to safely navigate the patient through the acute care setting. Focus is on improved clinical and financial outcomes.

Non Acute Setting Case Management Models

Primary Care Case Management-Combines the roles of caregiver and case manager and is often the model for homecare and SNF’s. Because of the dual roles there is potential for ethical conflict. This is also the federally legislated model of case management for the Medicaid plans of some states. 

Workers Compensation Insurance Model- The goal is to return the employee to work by facilitating appropriate and timely care. 

Payer Based Case Management- The case manager is an employee of the insurance company and acts as a liaison between providers and the insurance company to provide quality, cost effective care to the members. 

Disease Management- Focuses on groups of patients with conditions such as pregnancy or  chronic illnesses such as diabetes. Case Managers provide education and facilitate compliance with treatment plan.