Case Management Models: Best Practices for Health Systems and ACOs, Second Edition

Karen Zander, RN, MS, CMAC, FAAN

The role of case management in healthcare settings is continuously evolving to meet the needs of patients and manage the quality, financial, and legal risks health systems and accountable care organizations (ACO) face. Case Management Models: Best Practices for Health Systems and ACOs offers insight into how to structure case management models across the continuum of care to address these needs and risks. Definitions and rationale for fundamental models, including dyad and triad, are provided to illustrate the needed resources and recommended structure. Guidance on case management deliverables and outcomes is also included to demonstrate the value of case management.

This book explains the differences between case management and social work and the ways in which case management functions have evolved over time. Rationale for providing case management services in health systems and ACOs is also included along with suggestions for case management reporting structures. Whether your healthcare organization has an existing or developing case management department, this resource can help you select an appropriate model and seek staff with skills best suited to help you reach your goals.

This book will help you:

• Describe how case management professionals are accountable for deliverables 
• Determine which patients and families need case/care management across the continuum 
• Decipher how many social workers and RN FTEs are needed at each level of care 
• Explain how to use cost-benefit analysis to identify the best model for an organization 
• Discuss the various ways of classifying case management models used in health systems 
• Discuss how case management functions have evolved 
• Describe the precursors and rationale for health systems to establish case management services 
• Identify the seven fundamental components of case management models

About the Author:

Karen Zander, RN, MS, CMAC, FAAN, president and CEO of The Center for Case Management in Wellesley, Massachusetts, has more than 40 years of healthcare experience. In this role, she serves as a consultant and educator to hospitals, physicians, healthcare systems, and software, pharmaceutical, and consulting companies worldwide for the development of tools, roles, and systems to support provider-side control of cost and quality.

Zander previously was associated with New England Medical Center Hospitals (now Tufts Medical Center), where she served in multiple roles, including organizational development specialist in the nursing department, director of consultation in the Center for Nursing Case Management, inpatient/day hospital psychiatric service nurse leader, and staff education instructor. 


Published: July 28, 2017

Page Count: 190
ISBN: 978-1-68308-561-4 
Dimensions: 8.5" x 11" 

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Table of Contents

Chapter 1: Importance of Models

• The Appeal of Models
• Models in Healthcare
• The Politics of Models
• Categorizing Case Management Models Across the Continuum
• Case Management Models at the Patient/Family Level
• Bedside Bulletin: Case Management Narrative: “When I Made a Difference”

Chapter 2: Case Management Practice in Health Systems and Accountable Care Organizations: Coming of Age

• Defining Case Management and its Inherent Authority
• Models of Case Management Won’t Work without Physician Support
• Case Management Models Should Establish the Expert Authority of RNs and Social Workers
• Background: Drivers and Rational for Case Management Across the Continuum, including
• Four Drivers and Rationale for Building Case Management Across the Continuum
• Models that Will Improve Care
• The Evolving Core Model of Case Management Functions
• Bedside Bulletin: Think Like a Shark, Act Like an Octopus

Chapter 3: Case Management’s Position as the Engine in Health Systems/ACOs

• Case Management as the Health System’s Engine
• Scalar Process: To Whom Should the Case Management Department Report Across the Continuum?
• Bedside Bulletin: Your Network from Bedside to Boardroom

Chapter 4: Fundamental Components of Health System Case Management Models

• Components of Case Management Models
• Role of the Director or Manager
• CMS’ Conditions of Participation and The Joint Commission Requirements for a Hospital Plan
• Utilization Review/Case Management Committee
• Typical Department Structures and Personnel
• The Physician Advisor/Medical Director of Case Management
• Case Management Standards for Hospitals and Health Systems
• “Philosophy” of the Case Management Service Matters
• Bedside Bulletin: Care Coordination Rounds

Chapter 5: Health System Case Management Deliverables

• The Meaning and Importance of “Deliverables” to a Health System Board
• Data Dashboards: “Vital Signs” on Display
• Determining Accountability for Deliverables on the Data Dashboard and Matching Models to Deliverables
• Data Collection, Display, and Benchmarks
• Interpreting the Data Dashboard
• Presenting the Case Management Data Dashboard
• Creating a Sustainable but Fungible Model Across the Continuum: All Is Change
• Holding Case Management Professionals Accountable for Deliverables
• Bedside Bulletin: Complex Care Rounds

Chapter 6: Using the Evidence-Based Practice (EBP) Method for Case Management Model-Building

• What is EBP? 
• Emerging Patterns of Effective, Sustainable Models 
• Eight Key Model-Building Questions Incorporating EBP 
• Case Example: Transitioning from a Social Work to Social Work-RN Case Manager Model 
• Cost-Benefit Analysis: Finding an Effective and Sustainable Model 
• Bedside Bulletin: Role Clarification 

Chapter 7: Developing the Professionals in Case Management Models across the Continuum

• Teaching Skills to Enhance the Patient/Family Experience 
• Team Building Across the Continuum, Plus Tools 
• Teaching Skills for Working with Physicians 
• Teaching Skills for Managing Chronically Ill Patients 
• Teaching Skills for Population Health Management and Bundled Payment Initiatives 
• Teaching Skills for ED Case Management 
• Teaching Skills for Medical Homes and Specialty Neighborhoods 
• Teaching Skills for Community Case Management 

Downloadable Appendix with Tools and Forms