There’s increasing demand for case managers that focus on care coordination and advocacy in healthcare settings, from acute care to public health.
More medically complex patients, coupled with an emphasis on value-based care is forcing healthcare employers to focus on providing effective and efficient care.
Demand for case managers is increasing as a result of the need for employers such as hospitals to reduce hospital readmissions in order to maximize reimbursement.
“This growing demand stems from an increasing number of individuals who have multiple medical conditions, see numerous physicians, take countless medications and, unfortunately, are not served well by a healthcare system that is more convoluted and complicated than ever before,” said Catherine M. Mullahy, BS, RN, CRRN, CCM, President of Mullahy & Associates, which provides case management continuing education, certification, training, and support.
Ideally, case managers focus on this relatively small percentage of complex patients. They help these patients understand their diagnoses, get answers to their questions and monitor their treatment plan adherence.
They also act as their patients’ advocates, coordinating their care and ensuring patients get the best possible outcomes, according to Mullahy, speaker for Nurse.com’s Best in Class Case Management Online Focused CE Series.
Case managers who can focus on those most in need of highly specialized intervention can truly make a difference, Mullahy said. But there are hurdles to achieving the best outcomes from case management, and they include a lack of awareness among nurses and employers about this role.
Who Do Case Management Specialists Do?
Case managers work in many settings, but most often in acute care or in the insurance industry, in managed care or group health, according to the 2020 Case Management Salary and Trends Survey, by the Case Management Institute.
While criteria for identifying patients for case management intervention vary among employers and settings, patients who are the most likely candidates for case management are people with high-cost healthcare conditions. They include people with:
- Organ transplants
- Heart disease
- Complex diabetes
- High-risk pregnancies
Ideal patients for case management also include the families of preemie babies, people with a history of multiple hospital admissions and emergency room visits, as well as others with increasing numbers of complications.
Still, other patients who can benefit are those with:
- Cognitive impairment or mental health disorders
- Visual and hearing deficits
- Language barriers
- Elderly people who are living alone
- Members of the homeless population
Some people need only short-term case management, while others with long-term and progressive disorders, such as ALS, end-stage kidney disease, congestive heart failure, COPD or cardiac conditions, might need long-term intervention, according to Mullahy.
“When case management is used appropriately, outcomes for patients improve, patient satisfaction improves and care is coordinated, safe and cost-effective,” Mullahy said.
Case Managers Have a Specific Set of Skills
Most case managers are nurses, although social workers also are drawn to the profession. Case management is considered an advanced practice setting for nurses. And nurse case managers typically have at least 3 to 5 years of experience before transitioning into the role, according to Mullahy.
Salaries vary, but 51% reported making annual salaries between $70,000 and $89,000, according to the Case Management Institute report.
Nurses with diversified experience in a variety of clinical and practice settings, from acute care to home care and public health, make good case management candidates. They tend to better understand what patients might experience across the care continuum.
Other characteristics and qualifications that are help in case management include having good communication skills; critical thinking and creativity; the ability to function independently; leadership skills; and the ability to collaborate, Mullahy said.
“Case management is not for nurses seeking to escape the stresses of healthcare, because they really are working with the most complex patients,” she said. “While they no longer have direct patient care responsibilities, they encounter many, many other challenges. Case management is not for individuals who prefer or need more predictable working environments.”
The juggling act
Case managers might have other roles heaped onto their plates, which makes effective case management more challenging. For example, some hospital case managers do a combination of utilization review and case management. Or sometimes, case managers are more tasked with discharge planning than anything else.
A lot of case managers at hospitals are frustrated because they’re not able to provide case management for the most complex patients. Their caseloads and what they’re doing are not centered around the patients who need it most, Mullahy said.
Frustration leads to high turnover, which is a problem in case management. Nearly 80% of those surveyed reported average or high turnover in case management, according to the Case Management Institute report.
“What happens in a lot of hospitals is that everybody that comes into the hospital is seen by someone that has the title case manager,” Mullahy said.”But everyone that goes into the hospital doesn’t have the kinds of conditions or circumstances that require a case manager. It’s a problem for hospitals; it’s a problem for case managers.”
Job satisfaction in case management results when the case manager becomes not only an advocate for patients but who can teach them how to do the same.
“What we hope to do is inform patients, give them the information and the tools and resources so they eventually become their own case managers,” she said. “I really do believe we’re making a difference one patient at a time.”
The training regimen
Nurses aren’t trained in nursing school to be case managers. But because nurses often advocate on patients’ behalf, employers and nurses might think they can do the job without proper training.
“Transitioning from traditional roles in healthcare to that of case manager is, in and of itself, challenging. It’s not enough to be experienced as a nurse or social worker; the acquisition of ‘new’ knowledge is imperative,” Mullahy wrote in an article about trends in case management in the 2020 Case Management Salary and Trends Survey.
The new knowledge includes learning about community resources, payer systems, how to help a patient across the care continuum and more.
“When you go to any nursing program today, you don’t learn about Medicare and Medicaid, you don’t learn about financial reimbursement, you don’t learn how to negotiate for things. That’s what case managers do every day,” Mullahy said.
Three groups of nurses typically benefit from a course like the one Mullahy teaches for Nurse.com — nurses who want to transition into the case manager role but need to know more before making the move; nurses already hired as case managers, who haven’t been adequately trained for the role; and nurses who are experienced in case management and are preparing for the certification exam.
The gold standard in nurse case management certification is the Certified Case Manager (CCM) certification, according to Mullahy, who was on the original task force that created the CCM credential.
Of those surveyed in the Case Management Institute report, 63% of case management professionals held a national case management certification, with 82% of those having CCM certification.
Case management training and certification are becoming increasingly important with the increase in roles and responsibilities, according to the Case Management Institute report.
“This will require the need for professional case managers to acquire new skills and reflects the importance of training, both at the start and throughout our careers as value-based is integrated into every sector of the US healthcare system,” wrote Case Management Institute CEO Deanna Cooper Gillingham, RN, CCM, in the 2020 Case Management Salary and Trends Survey.