Written by Frank Tucker

Health care is overly complicated to navigate and Peter Drucker hit the mark when he said it is, “the most complex human organization ever devised”.  Clinical Case Managers help patients navigate the complexities of healthcare. Clinical case management focuses on the coordination of services for an individual in various health care settings, like in the hospitals, mental health institutions, undergoing rehabilitation, people with disabilities, homeless, etc. It is the job of the case manager to facilitate, channel the communication to the respective agencies for the patient to have a cost-effective health care cost.  Clinical Case Management according to the Case Management Society of America (CMSA) is defined as a collaborative approach in terms of planning, coordination of care, facilitation, advocacy, which aimed to support the patient and its support system, to meet the health care needs of the patient.  The functions of Clinical Case Management are also well articulated  in the five basic functions of case management according to JCAH, as cited in Kanter, Joel’s electronic PDF, “Theory and Practice of Clinical Social Work, (2010); assessment, planning, linking, monitoring and advocacy.

The high cost of health care services have prompted many health care agencies to tap the expertise of a Clinical Case Manager. The hospital related cost per day paid by the primary payer, as cited in authors, Anne Pfuntner, Lauren M. Wier, M.P.H., and Claudia Steiner, M.D, in the published article entitled “Cost for Hospital Stays in the United States, 2010, is estimated at $12,100 and $12,300 for adults ages 45-64 and 65-84. The aim of clinical case management is to help the individual not just the patient achieve the optimal wellness through advocacy, education, communication by providing the information related to the services offered by different organizations/agencies that provide various support and assistance to individuals, and to ensure that the resources are effectively utilized by the individual. The primary responsibility of a Clinical Case Manager is to provide a comprehensive care management and coordination, ensuring the individual’s health and well-being at all times.

In the study entitled, “Cost-Effectiveness of Effectiveness of clinical case management for ED (Emergency Room) frequent users: results of a randomized trial,” authors, Shumway M, Boccellari A, O’Brien K, Okin RL, found out that case management appears cost-effective for frequent ED users such as individuals who lack health insurance and social security income and financial needs, homeless and alcohol use, because it yields statistically and clinically significant reductions in psychosocial problems at a cost similar to that of usual care. The cost effective nature of managing utilization through case management is also illustrated in a previous blog article on Reducing Emergency Medical Service Utilization through Case Management.  In that article, we we discussed the value of case management in reducing emergency service utilization by not only managing health care services but also social services.   A good Clinical Case Manager will determine the relevant agencies that can help and support the patient towards optimum recovery, while considering financial concerns of the services provided by the state or other private groups.  They are also responsible for coordinating the patient’s insurance provider, follow-up any secondary treatment modality like rehabilitation, facilitating hospice care or simply helping out patient’s prescriptions.

Clinical Case Managers typically have attained a Bachelor of Science in Nursing or related four-year degree and certification.  They must also have extensive experience in the health setting.  This helps ensure they have the broad knowledge needed as they help ensure effective and efficient utilization of services through techniques like utilization management. With deep clinical experience, they help manage the patient care plan using practices like disease management.  However, the unseen and often intangible benefit is that they help the patients navigate the complexities of health care services so that the care plan and care coordination is synchronized and executed for better patient outcomes.