Managed care systems like HMOs and PPOs aim to control healthcare costs by establishing networks of providers and using utilization management. They may use capitated reimbursement instead of fee-for-service. Case management also aims to improve quality of care and reduce costs through coordinated care plans. It involves assessing needs, planning care, implementing and coordinating the plan, and monitoring outcomes. Case managers are certified through examinations in case management, disability management, or advanced care coordination. While similar, case management addresses individual needs while disease management focuses on populations with chronic illnesses.

1. Managed Care & Case
Management
Medical Surgical
Critical Thinking
For
Collaborative Care

2. Learning Objectives
• Explain the primary purpose of Managed Health Care
• Contrast the fee-for-service and capitated
reimbursement systems for health care
• Compare the Health Maintenance Organization with
the Preferred Provider Organization
• Delineate the overall goals of Case Management
• Explain the role of Case Management based on
National Standards
• Identify at least three certifications for Case Managers
• Clarify the differences and similarities between case
management and disease management

3. Managed Health Care
• A system that attempt to control cost by using select
group of providers who have agreed to a set payment
before delivering care
• Client care is outcome driven & managed by a
utilization and or case management process
• Factors driving cost and quality
• Aging
• Purchaser pressure to contain costs
• Physician & consumer resistance to “tight”
management and referral control
• Renewed emphasis on evidence-based practice

4. Managed Care
• Fee-for-service – hospital, physicians, and
other health care providers were paid by
health insurance companies on the basis of
what the providers billed for their services
• MCOs standardize and control cost
• Health care providers receive a uniform
amount of money for each client—capitated
reimbursement
• MCO – HMO, PPO

5. Case Management
• The assumption the client need assistance using the health
care system and its resources effectively
• Goals: By ANA
• To provide quality health care along a continuum of care
• To decrease fragmentation (and duplication) of care across
health care settings
• To enhance the client’s quality of life
• To increase cost containment (thru appropriate use of
resources)
• BY CMSA: To enhance an individual’s
safety, productivity, satisfaction & quality of life
• To assure that appropriate services are generated in a
timely and cost-effective manner

6. Process of Case Management
• Needs Assessment
– Assess/collect data
– Conducts case screening
– Identifies client’s support systems and care providers
– Review history and determines current health care needs obtains approvals for contracts
• Plan Development
– Identifies services and funding options
– Reviews plan for consensus
– Advocates for client as needed
– Develop plan of care as indicated
• Implementation & Coordination
– Communicates regularly w/client and support system
– Coordinates treatment plan
– Promotes coordinated and efficient care
– Identifies needs for additional services
• Outcomes Monitoring and evaluation
– Assess benefit value to cost & value to quality of life
– Review plan for continuity of care
– Evaluates client satisfaction and compliance w/treatment plan
• Documentation
– Records services and outcomes
– Submits report & other documentation as needed

7. Standards for Case Management Practice
• The standards describe
responsibilities, delineate expectations, &
define accountabilities:
• Roles includes:
assessment, planning, facilitation, and
advocacy
• Three certifications:
• CCM – certified case manager
• CDMS – certified disability management
specialist
• A-CCC – advanced certification in continuity of
care

8. Differentiations
• Disease management is across the
continuum, system-based approach to care for
populations of clients w/ chronic, complex
illnesses; it uses case management as the
process for providing care.