What is care management?

Care Management: A Comprehensive Approach to Coordinated Healthcare

Care management is a process of needs identification and service coordination designed to maximize function and independence while recognizing an individual's right to self-determination, essential for people with chronic diseases and complex healthcare needs. 1

Definition and Core Components

Care management involves a structured approach to coordinating healthcare services across multiple providers and settings. The fundamental components include:

• Screening and case finding to identify individuals who would benefit from care management 1
• Comprehensive assessment of patient needs across medical, psychological, functional, and social domains 1
• Care plan development that addresses identified needs 1
• Implementation of the care plan through coordinated service delivery 1
• Ongoing monitoring and adjustment of the care plan as patient needs change 1

Key Elements of Effective Care Management

Team-Based Approach

• Care management is ideally provided by a multidisciplinary team including physicians, nurses, and/or social workers 1
• The care management team must be linked to the patient's primary or continuing medical care 1
• While one qualified health professional may perform care management functions, the process involves coordinating multiple providers across all care settings 1

Patient-Centered Focus

• Patients and/or surrogates must actively participate in formulating the individual care plan 1
• Patient empowerment in determining services is essential to the care management process 1
• When services are denied or restricted, patients must be promptly informed and given the right to appeal 1

Comprehensive Scope

• Effective care management addresses the medical, psychological, functional, and social domains of health care 1
• It coordinates health and social services with family-provided care 1
• Care management helps control unnecessary utilization and costs while ensuring quality of care 1

Benefits of Care Management

Research has demonstrated several benefits of care management:

• Increased services and reduced unmet needs for patients 1
• Increased patient confidence in receipt of care 1
• Improved life satisfaction 1
• Better disease control in patients with multiple chronic conditions 2
• Improved quality of life and greater satisfaction with care 2

Challenges and Considerations

Potential Conflicts of Interest

• When the care manager is also a service provider, there may be conflicts of interest 1
• Services might be provided based on agency profit rather than patient need 1
• Conversely, services might be inappropriately restricted if the manager is at risk for the cost of care 1

Funding Issues

• Funding for care management services is neither uniform nor fair 1
• Multiple reimbursement mechanisms (Medicare, Medicaid, private insurance) create a confusing array of service providers and eligibility requirements 1
• Current fee-for-service systems present barriers to widespread implementation of care management 3

Modern Approaches to Care Management

Recent developments in care management include:

• Collaborative management approaches that strengthen self-care while ensuring effective medical interventions 4
• Goal-oriented care that focuses on what matters most to each person over their life course 5
• Care management within primary care settings, which may generate cost savings 3
• Programs supporting patient transitions from hospital to home, which have been particularly successful in reducing hospital readmissions 3

Successful Implementation Elements

The most effective care management programs include:

• Accurate identification of patients who could benefit from care management 3
• Specially-trained registered nurse care managers with low patient loads 3
• In-person patient contact 3
• Active and sustained follow-up to monitor health status and progress 4
• Collaborative definition of problems that includes patient-defined concerns alongside medical diagnoses 4