What is Case Management in Nursing?

• Although at times it can be demanding, case management in nursing is an extremely rewarding practice.
• From assessing medical necessity, to collaborating with healthcare providers and developing discharge plans at the appropriate time and level of care, case managers are an essential part of a patient’s healthcare journey. 
• Are you interested in pursuing case management in nursing? Let’s find out!

So, you are looking to get away from the bedside but stay close to the patient – what can you do? 

Case management in nursing might be the next step for you!

A History Lesson of Healthcare Reimbursement

Prior to case management in nursing, insurance companies paid for catastrophic or acute hospitalization care and the patient paid some deductibles.  

Patients would stay in the hospital not only during the acute phase of illness but also for convalescent care. 

In 1987, I had a patient on my post-op floor who was waiting for a long-term care bed (short-term rehab facilities did not exist at this time) and stayed with us for 9 months; imagine that now! 

In my own patient experience, after my first C-section, my doctor invited me to stay in the hospital a little longer and said our insurance company would pay; I stayed for 10 days! I also had a pilonidal cystectomy and stayed in the hospital for 4 overnights. I remember women going to the hospital for a “rest” because they were stressed or overworked. 

Can you picture this happening now?  Absolutely not. 

The patient paid for all outpatient physician visits and were reimbursed only after an annual deductible was met. 

Physicians practiced as single entities with one or two staff members. 

Healthcare costs began to soar with the emergence of new methods, technology, and equipment.   

In the 1990’s, a new reimbursement and care method emerged known as, Managed Care.   

The Centers for Medicare and Medicaid (CMS) as well as insurance companies were looking for a way to reduce costs and realized that illness prevention would pay off in the long run for both the patient, and of course, the payers.  

It was a concept that prevailed in some countries during ancient times. Doctors were paid (by the patient) only if the patient stayed well. If the patient became ill, they were not reimbursed.   

Medicare and insurance companies decided if we prevented illness and assisted the patient to understand and care for their illness, we potentially could save healthcare dollars to be utilized for those with the most needs.   

Hence, the huge push for preventive care and case management in nursing arose. 

A similar system for method of payment is still in force today.  

For the first time in American history, doctors were becoming incentivized financially to provide preventive care.   

So, the question is, “what does reimbursement in today’s healthcare system look like?”   

Simply put, an entity (facility or physician group) is given a virtual budget for patients in their practice by CMS or the insurance company. This budget is determined by the facility’s patients’ demographics: age, gender, risk of illness or actual illness, zip code or county, and a variety of other items.   

This virtual checkbook is held by the insurance company or Medicare and contains specific measures a group must meet. These measures include preventive care, medically necessary care, appropriate utilization of equipment, and more.   

As you can imagine, this made for an increase in demands of practices and facilities in order to provide appropriate reporting, coding and billing (to reduce fraud).  

For physicians to be able to do all of this, they began to practice in groups, needing to hire more support staff.  Hospitals began to merge with other hospitals and outpatient facilities.   

To ensure the patient panel received the most appropriate care at the appropriate level of care, hospitals and physician groups needed more assistance in determining where the patient was on their health care journey or if they needed education, advocacy, or triage assistance; hence, case management in nursing began.  

What is Case Management in Nursing? 

According to the Case Management Society of America (CMSA), case management is 

“a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost-effective outcomes.” 

Sound familiar?   

Case management in nursing still encompasses the nursing process to assess, plan implement and evaluate for the most appropriate level of care for the patient. 

Nurse.org highlights that case managers can be found in facilities such as hospitals, skilled nursing facilities, long-term care, home care agencies, insurance companies, and independent practices. 

The primary goal of case management in nursing is to coordinate care, educate, and advocate for the patient while evaluating outcomes and working with other providers along the way. 

It is important for nurse case managers to understand the insurance coverage a patient might have, as it assures that the facility will be paid appropriately for any services.

Medical Necessity 

Case managers (and all RNs) must understand a concept known as medical necessity.   

Very Well Health outlines that although this term’s verbiage might vary per insurance or CMS provider, medical necessity “refers to a decision by your health plan that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem.” 

 This ensures the patient will receive the most appropriate care at the most appropriate level of care.  These guidelines can be found on websites such as the CMSA, which is the first entity to develop education and promote case management in nursing. 

Case Management in Nursing: What Do They Do? 

In a facility, case managers work with patients and their families or support systems to ascertain medical necessity in the facility. On top of this, they also plan for discharge in the most appropriate setting and level of care.  

As always, it is extremely important to include the patient in all plans. In some instances, case managers will be invited to grand rounds as well as other planning meetings to discuss issues and or communicate plans of care. 

My career as a case manager began at a major insurance company in Massachusetts.  

Following, I also spent time as a case manager in a large Physician Hospital Organization (PHO), skilled-nursing facility, and an Accountable Care Organization (ACO). 

Currently, I work as a self-employed, independent case manager. 

Although at times it can be demanding, case management in nursing is also a very rewarding practice. It utilizes all of the skills and education we have as nurses and allows us more time to spend with patients and their families.

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