Outpatient Case Management: Strategies for a New Reality
Michelle Regan Donovan and Theodore A. Matson, editors
American Hospital Publishing, Chicago
1994, 298 pp., $48.95 (AHA members), $58.95 (nonmembers) (paperback)
As the healthcare delivery system evolves, the need for acute inpatient care is diminishing markedly. Service delivery strategies must now be designed to create an uninterrupted continuum that includes inpatient, outpatient, and ambulatory-care settings. Michelle Regan Donovan and Theodore A. Matson, the editors of Outpatient Case Management: Strategies for a New Reality, see case management as the best way to coordinate a spectrum of multidisciplinary services. They call for a holistic care plan that will accommodate the specific needs of each patient.
In their book, the editors have brought together 23 articles by 30 writers. Outpatient Case Management is aimed at board members, administrators, physicians, therapists, nurses, payers, and consumer advocates — in short, all those who should be involved in the reengineering of the healthcare delivery system.
The book is divided into three sections. Part I gives a general description of case management and shows why the case manager should be the coordinator of primary care. Part II offers 16 case management models. Part III is a selective annotated bibliography of the case management literature.
In the book's first chapter, Matson examines the effect of marketplace dynamics on healthcare, in particular the shift from inpatient care to outpatient care. Citing pertinent examples, the author shows how providers, employers, and payers have collaborated in the making of this trend. Matson also outlines several plans that providers might use to restructure their delivery systems.
In chapter 2, Donovan advises providers to be flexible in making the difficult transition from inpatient to outpatient care. There is, she writes, a "window of opportunity" during which they can establish clinical pathways and a system of outcomes measurement and management. Donovan says that all case management applications are based on five functions: assessment, planning, intervention, monitoring, and evaluation.
Private-sector payers want to control costs while, at the same time, improving the health of the persons they cover. In chapter 3, Steven Sieverts suggests that case management can help providers do both. The primary purpose of case management is, of course, to help patients. But, Sieverts writes, because case managers are aware of community resources and have contracts with providers outside acute care hospitals, they can "shop" for low-cost modes of patient care, thus holding down costs to the payer.
In chapter 4, David P. Moxley, PhD, focuses on the importance of systematic preparation in designing an outpatient case management program. He says that the designers should first determine the program's mission, the composition of its staff, and whether its decisions are to be made by a team or an individual. For the program to be effectively implemented, Moxley writes, its staff must make use of outcomes measurement and management. To avoid possible ethical problems, he says, the staff must inform clients of both the program's strengths and its limitations.
In chapter 5, Elaine M. Sampson outlines the two distinct types of case management that have so far emerged: a "fiscal" system, in which the case manager is primarily concerned with the cost of services and the patient's eligibility for them; and a "clinical" system, in which the case manager provides justification for whatever services are necessary to meet the patient's needs. Sampson also offers models that mix the "fiscal" and "clinical" types. She argues that nurses make good case managers and program administrators because of their professional training and experience in interacting with other providers, especially physicians. Sampson suggests that, for programs that target specific disease categories, clinical nurse specialists make ideal administrators.
To market outpatient case management to physicians and other customers, Sampson writes, the case manager must persuade both inpatient and outpatient care providers that he or she can effectively communicate with them about the needs of their patients. Case managers will enhance their relationships with physicians by providing them with dependable, high-quality reports, Sampson adds.
In chapter 6, Gerry Brueckner and Talar Glover argue that case management is itself the medium of communication critical to the new continuum of care. Case managers guide both patients and care givers through what would otherwise be a bewildering array of services. To contain costs and maintain quality, they suggest, service lines need to be integrated in all settings and comprehensive care plans developed.
In chapter 7, Dawn Lajeunesse discusses "The Caregiver as Case Manager." And, in Outpatient Case Management's remaining 16 chapters, writers suggest a number of case management models, including case management in pediatrics, rehabilitation, services for the elderly, and other fields of care.
The book provides a clear overview of how outdated organizational practices can be redesigned to comply with the demands of managed care. In addition to the new insights provided, I was especially impressed by the practical guidance put forth to suggest how these changes can be implemented in a multitude of areas. This type of thinking will be necessary to create superior and more productive organizations.
Adam R. Wychulis, MD
Vice President, Medical Affairs
Saint Michael's Medical Center
Newark, NJ