Case management in healthcare is emerging as a critical intervention designed to enhance the care of frequent users—those who disproportionately strain resources with repeated healthcare and social service needs. Defined broadly, case management encompasses a suite of interventions including individualized care plans, patient education and collaborative problem-solving, all aimed at improving patient outcomes. Through a strategic, cooperative process, case managers work alongside various healthcare providers to evaluate, plan, and coordinate a tailored approach based on each patient’s unique requirements.
Why do health plans implement case management?
Health plans today increasingly prioritize case management as a strategic response to the multifaceted challenges of delivering high-quality healthcare. The goal of these plans, as stated by the Case Management Society of America, is twofold: to enhance member health outcomes and manage the spiraling costs associated with chronic conditions. Health plan members with chronic health issues often incur disproportionately high costs due to frequent hospitalizations, emergency room visits, and the need for specialized care.
As highlighted by recent studies, approximately 10% of patients are responsible for about 70% of all healthcare costs. Further statistics show that 5% of emergency department patients make up 30 to 50% of visits, most of whom struggle to meet their healthcare needs. This scenario leads to either excessive use of costly services or insufficient and disjointed care, which reiterates the need for strategic case management to create a more sustainable healthcare model. Therefore, case management plans help ensure patients receive the necessary care precisely when it’s needed, improving the management of chronic conditions and thereby reducing these recurrent, costly healthcare interactions.
Equally as important is a care plan’s ability to help healthcare providers meet member expectations and boost satisfaction. A well-defined plan can help members navigate the complex healthcare system while addressing broader issues such as healthcare disparities and tackling social determinants of health, such as food insecurity, transportation, and access to care, making healthcare more equitable. Promoting care coordination and continuity closes gaps in care and enhances communication between multiple providers involved in a member’s care. This coordination ensures that all parties—members, family members, and healthcare providers—are on the same page, which is crucial for effective treatment and preventing care disparities.
While yes, it may be difficult to coordinate a perfectly executed plan given the sheer number of parties involved, when done successfully, positive outcomes in case management can lead to better accountability, defined roles, and targeted interventions.
How does it work?
Drawing on the results procured by various global studies, the core components of case management in healthcare begin with the critical step of identifying individuals who require intensive support through risk stratification tactics—typically those with complex needs and chronic conditions. Given that a small fraction of the population often consumes a large share of healthcare resources, targeting these high-risk individuals ensures that interventions are both effective and cost-efficient.
Once individuals are identified, a thorough assessment is conducted by a case manager. This assessment evaluates not just the medical needs but also the social and functional abilities of the individual. Many of those selected for case management have multifaceted health and social care requirements, making a comprehensive approach to assessment vital for crafting an effective care plan.
It is only when the individuals have been identified that the care can be coordinated effectively through ongoing communication with the members, their caregivers, and various health professionals and services they interact with. The case manager, often supported by a multidisciplinary team, plays a rather navigational role in organizing and managing the care process.
Monitoring and follow-up are integral to ensuring the care plan remains suitable for the individual’s needs. Depending on the severity and specifics of the case, monitoring can range from daily to monthly and can be conducted in person or remotely, using tools like telehealth devices which allow for oversight that allows for the necessary adjustments to the care plan based on the evolving needs of the patient.
Addressing socio-economic barriers that often lead to hospitalizations is then done by effective resource management. Adobe’s proprietary application, MASLOW™ is employed to detect and address gaps in care. By automatically identifying and geolocating social support resources—such as food, shelter, and transportation—MASLOW™ ensures that socio-economic needs are recognized and actively managed. Social workers use this data to help members access required services, closing the gap between healthcare provisions and social determinants of health.
Case management is as structured as it is flexible. It is this non-linear and dynamic nature, involving repeated cycles of assessment, planning, and review, that allows modern healthcare systems to adapt continuously to meet the changing needs of patients.