Case Management Guide to Population Health: Management Across the Continuum of Care

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Case Management Guide to Population Health: Management Across the Continuum of Care

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Available October 2017

Case Management Guide to Population Health: Management Across the Continuum of Care

Mary McLaughlin-Davis, DNP, MSN, NEA-BC, APRN-BC, CCM

Available October 2017

Dramatic changes are occurring in healthcare as pay-for-quality and performance improvement continue to drive innovations in care delivery. One of the changes that is fast becoming a critical outcomes driver for provider organizations is population health management. While this new model has been demonstrably effective at achieving better patient outcomes at a lower cost, case managers need resources and guidance on how to approach an overhaul to their program.

Case Management Guide to Population Health: Management Across the Continuum of Care is a comprehensive playbook for ensuring the effectiveness of a population health program. This resource is designed to help case management and other healthcare professionals examine social determinants of population health, gauge the sustainability of population health modules in case management, and measure case management outcomes.

About the Author:

Mary McLaughlin-Davis, DNP, MSN, NEA-BC, APRN-BC, CCM, is national president for the Case Management Society of America (CMSA) and is an active member of CMSA’s Public Policy Committee. Davis is a senior director of care management for the Cleveland Clinic Health System and an adjunct nursing faculty member at Ursuline College. She has provided care coordination services for inpatients, outpatients, and healthcare plans. As a clinical nurse specialist, Davis has worked extensively with patients having chronic disease, notably congestive heart failure and stroke.


Dimensions: 8.5 X 11
Page Count: 150
ISBN: 978-1-68308-497-6

Table of Contents:

1. Population Health: A Journey and a Destination for the Case Manager

a. Alternative payment models 
b. Public health model 
c. Customers/stakeholders

2. Integrated Case Management

a. The impact of the case manager on chronic medical conditions 
b. The impact of the case manager on chronic behavioral health conditions

3. The Case Manager’s Evolving Role

a. Historic 
b. Current

4. The Case Manager and the Interprofessional Team 

5. The Case Management Assistant

a. The role of the non-licensed assistant

6. Social Determinants of Population Health

a. Literacy/health literacy 
b. Financial security 
c. Food/shelter 
d. Transportation/access to system 
e. Patients/clients/veterans at risk

7. Patient/Client/Veteran-Centered Care

a. Assessment 
b. Motivational interviewing 
c. Patient/client/veteran-centered goals 
d. Patient activation/patient engagement

8. Transitions of Care

a. Hospital 
b. Post-acute care 
c. Home

9. Tools for the Case Manager

a. Standards of practice for case managers 
b. Commercial software programs

10. Measuring Case Management Outcomes

a. PHQ-9 
b. HCAHPS 
c. CAHPS 
d. PAM 
e. Readmissions

11. Sustainability of Managing a Population Health Model With Case Management