Academic journal article Health Care Financing Review

Case Management, Client Risk Factors, and Service Use

Academic journal article Health Care Financing Review

Case Management, Client Risk Factors, and Service Use

Article excerpt

INTRODUCTION

The term "case management" has come to describe a method of organizing a fragmented group of service providers (and sometimes funding sources) at the point of service delivery. One impetus for the initial growth in this approach was the expansion in community-based care options for persons needing some form of long-term care (Weil and Karls, 1985). Case managers in these programs may determine benefit eligibility and develop care plans for those electing to remain outside of nursing homes. On a more limited scale, case-management functions have begun to be extended to the interface between acute care (and even primary health care) and a multitude of community care services. Community services include skilled care such as home health and nursing homes, as well as "non-skilled care" such as residential care, day care, meals programs, and homemaker/chore services. Case management in this context can range from simple referrals to serving as a point of information coordination between multiple providers. The incorporation of case management into health care delivery is being stimulated by (a) the recognition that large numbers of elderly persons with chronic conditions require treatment that is inappropriate for acute care settings; (b) funding for in-home and community-based care from Medicaid waiver programs; (c) advances in medical practices that have resulted in many types of medical and surgical care being practiced outside the hospital in community-based or home settings; and (d) recognition of communication problems between primary care providers and medical specialists and other providers (Applebaum and Austin, 1990; Mor, Piette, and Fleitmann, 1989; Rothman, 1992).

Case management is now considered a pivotal component of long-term care service delivery and as a likely adjunct to primary care in managed health care systems (Grower, 1997; Kane, 1985). Inpatient and nursing home case-management teams may also be gaining prominence. The utility of case management is based more on its face validity than on scientifically documented success. The two major evaluations of community-based case-management interventions, the Channeling demonstration (cf., Kemper, 1990) and the Medicare Alzheimer's Disease Demonstration (Newcomer et al., 1992), as well as a number of other demonstrations using case management as part of community-based long-term care services (cf., Berkeley Planning Associates 1986; Kemper, 1988; Kemper, 1990; Mathematica Policy Research, Inc., 1986; Weissert, 1985; Weissert, 1988) have generally failed to find a cost savings resulting from case-manager interventions. These programs, particularly those able to reimburse community services, have shown that they can improve access to and use rates of community care.

Several studies conducted in Great Britain have found a therapeutic benefit. As early as 1970, British researchers concluded that the provision of support services to families of elderly persons with dementia enabled them to cope longer and thus maintain elders at home (Sainsbury and Grad de Alarcon, 1970). More recently, community-wide studies in townships such as Gloucester, East Kent, and Edinburgh showed that, through early intensive case-management efforts, the number of geriatric hospital admissions was reduced by as much as 60 percent, hospital stays were shorter, and the probability of admission to residential care declined substantially (Barker, 1985; Davies, 1988). Anecdotal studies that measure caregiver burden and satisfaction with services have also produced positive findings (Gilhooly, 1984).

In focusing on variables predicting positive outcomes, British researchers (unlike the United States studies) were led to examine the "core tasks of case management" and concluded that "the importance of recognizing the core tasks is that their performance directly affects most aspects of efficiency" (Davies, 1988). The British literature reflects attempts to go deeper into the multidimensional, managerial, coordinative, and clinical functions of case management. …

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