Center for Civic Partnerships

Medical/Chronic Disease Case Management

Top Tips

Different groups use the term ?case management? to define a wide range of services. While there are a variety of potential methods, each case management effort should seek to determine what services and supports the clients need, help them receive the services, follow up to ensure that they get the services/supports, track the effect they have and make any needed adjustments.

As this description shows, case management requires a thorough assessment and ongoing involvement with the individuals involved in the program. It is important to have sufficient trained staff to meet the needs of the clients, as well as strong linkages to other agencies that can provide the needed services. Data collection and tracking are critical to monitoring the impact of the effort.

Some of the important components/activities of case management programs include:

A comprehensive initial assessment
Involvement of the client (and possibly his/her family) in developing the plan
Timely and effective communication among the case manager, service providers and client
Developing and implementing a care plan
Advocating for the client?s needs and respecting his/her rights
Monitoring treatment progress, including ability to access services

Many case management programs use an integrated approach where a team of staff from multiple agencies work together to assist individuals in determining their needs, providing services and monitoring whether health improvement goals are met. This approach can assist with continuity of care for individuals who have multiple or complex needs.

Online Tools and Resources

AARP (formerly American Association of Retired Persons)
www.aarp.org/confacts/health/chrond.html
This web site provides tips for chronic disease management and links to resources.

Canopy Central - The Case Manager's Home on the Web
www.canopycentral.com
Sponsored by the Case Management Society of America and Canopy Systems, Inc., this site includes a variety of health and case management news, articles, links to continuing education opportunities and outcomes research, job listings, program models, surveys and discussion groups.

Case Management in Service Integration: An Annotated Bibliography
www.nccp.org/publications/sibtext.html
This page appears on the National Center for Children in Poverty?s website and is a list of publications related to case management and service integration.

Case Management Resource Guide
www.cmrg.com
Sponsored by Wyeth Pharmaceuticals, this on-line resource guide allows you to search more 120,000 health care services and support organizations, continuing education and disease management programs, manufacturers of homecare and assistive technology products and patient information.

Case Management Society of America
www.cmsa.org
CMSA is an international not-for-profit membership society of case managers, nurses and allied healthcare professionals. The website contains a searchable database of more than 50 categories on case management, services and resources, a bookstore, self-paced web-based continuing education trainings and conference information.

Center for Disease Control?s National Center for Chronic Disease Prevention and Health Promotion
www.cdc.gov/nccdphp/
This site provides information on chronic disease prevention, comprehensive approaches, training and resources.

Chronic Disease Self-Management Program, Stanford Patient Education Research Center
www.stanford.edu/group/perc/cdsmp.html
The Chronic Disease Self-Management Program is a six-week series of workshops offered in community settings such as senior centers, churches, libraries and hospitals. It is designed to enhance regular treatment and disease-specific education. The program gives people who have more than one chronic condition the skills to coordinate all the things needed to manage their health and keep active. Additionally, the program is available in Spanish.

HIV Prevention Case Management - Literature Review and Current Practice
www.cdc.gov/hiv/pubs/pcml/pcml-doc.htm
These guidelines from the Center for Disease Control focus on Prevention Case Management (PCM) for HIV and include a description of the model, literature review and evaluation results. Some of the material may be appropriate for other case management programs.

Models That Work Campaign ? Bureau of Primary Health Care
www.bphc.hrsa.gov/mtw
Sponsored by the U.S. Department of Health and Human Services, this program identifies and promotes the replication of innovative community-based models for the delivery of primary health care to underserved and vulnerable populations and includes several case management examples. Visit www.bphc.hrsa.gov/mtw/mtww4.htm for information on a managed-care program for indigent residents in Hillsborough County, Florida.

Suggested Reading

Aspen Health & Administration Development Group. (1996). Chronic Disease Management: Clinical Pathways & Guidelines. Aspen Publishers. Provides clinicians with guidelines that span the continuum of care for five chronic disease states. Also addresses the essentials of administering a disease management program. To order a copy: call 1-800-638-8437 or visit www.aspenpub.com.

Aspen Health & Science Development Group (1996). Chronic Disease Management Patient Education Manual. Aspen Publishers. Includes 200 large print handouts that help patients and families control chronic illness. To order a copy: call 1-800-638-8437 or visit www.aspenpub.com.

Carneal, G. and Caprio, L. Case Management Trends: An Overview of Recent Industry and Regulatory Developments. URAC/CMSA. Provides an overview of 7,300 case management regulations and statutes from all 50 U.S. states and the District of Columbia as well as the federal government. Also analyzes the current trends in case management regulation. To order, visit the American Accreditation HealthCare Commission?s web site at: https://webapps.urac.org/bookstore/bookdetail.asp?id=51&APID=CMSA.

Cesta, T.G; Tahan, H.A; Fink, L.F. (1997). The Case Manager?s Survival Guide: Winning Strategies for Clinical Practice. New York: Mosby, Inc. Focuses on nursing care management and includes a practical guide to planning, implementation and evaluation of case management programs. To order a copy visit: www.amazon.com (ISBN 081511771X).

Center for Disease Control, National Center for Environmental Health. (updated 2/11/03). Managing Elevated Blood Lead Levels Among Young Children: Recommendations from the Advisory Committee on Childhood Lead Poisoning Prevention. Written primarily for case management providers and for health department personnel who oversee case management follow-up for children with elevated blood lead levels. Includes an overview of case management activities and a table of a possible plan. To download the report, visit www.cdc.gov/nceh/lead/CaseManagement/caseManage_chap1.htm.

Jinnett, K., Alexander, J. and Ullman, E. (April 2001) Case Management and Quality of Life: Assessing Treatment and Outcomes for Clients with Chronic and Persistent Mental Illness. Health Services Research. This article examines the impact of treatment setting and exposure to case management services on the quality of life of U. S. veterans with chronic and persistent mental illness. Download from Findarticles.com at: www.findarticles.com/cf_0/m4149/1_36/74524590/p1/article.jhtml?term=case+management.

Morgenstern, J., Riordan, A., McCrady, B., McVeigh, K., Blanchard, K., and Irwin, T. (January 2001). Intensive Case Management Improves Welfare Clients? Rates of Entry and Retention in Substance Abuse Treatment. This report presents preliminary findings of a study conducted in New Jersey comparing the rates of entry and retention in substance abuse treatment for two contrasting intervention approaches: Care Coordination and Intensive Case Management. Findings indicate the benefits of providing intensive case management services over a more limited triage and referral system. Download from U.S. Department of Health and Human Services at http://aspe.os.dhhs.gov/hsp/njsard00/retention-rn.htm.

Morley, E. and Rossman, S. (1997). Helping At-Risk Youth: Lessons from Community-Based Initiatives. The Urban Institute. Based on lessons from the Communities in Schools and Safe Futures initiatives, this report includes a chapter devoted to service integration and case management. Download free from: www.urban.org/UploadedPDF/helpyouth.pdf.

Moxley, D.P. (1989). Practice of Case Management. SAGE Human Services Guides, Volume 58: SAGE Inc. This guide includes information on assessing needs, connecting clients with necessary resources and monitoring quality of service. To order a copy, call 1-800-818-7243 or visit www.sagepub.com.

Murer, C.G; Brick, L.L. (1997). The Case Management Sourcebook: A Guide to Designing and Implementing a Centralized Case Management System. Portland, OR: New Book New, Inc. A guide to understanding, developing and implementing healthcare case management. To order a copy visit: www.amazon.com (ISBN 0786312211).

Prior, K. (October 1998). Case Management Considerations and Systems. Healthy Start Field Office. This tip sheet provides ideas to consider before implementing a case management tracking system.

Raiff, N.R and Shore, B.K. (1993). Advanced Case Management: New Strategies for the Nineties. SAGE Human Services Guides. Volume 66: SAGE Inc. Describes innovations in outreach, planning, assessment and service interventions and includes culturally sensitive and other alternative approaches for engaging individuals, family members and other natural supports. Highlights areas of staffing, training, system building, interprogram coordination and resource control. Uses examples from a variety of fields to demonstrate model approaches and case management's ability to evolve with the changing times. To order a copy, call 1-800-818-7243 or visit www.sagepub.com.

Siefker, J., Garrett, M.B, and Genderen A.V. (1998). Fundamentals of Case Management: Guidelines for Practicing Case Managers. New York: Mosby-Year Book. Written collaboratively by nurses this book is for experienced and new case managers. It focuses on the basics of case management, insurance and legal issues. To order a copy visit: www.amazon.com (ISBN: 0815124988).

Zander, K. (1995). Managing Outcomes through Collaborative Care: The Application of Care Mapping and Case Management. Quality Press/American Society for Quality. This publication offers guidance for using caremapping and case management strategies to create a model for collaborative care that maintains or improves the quality of patient care. To order, call 800-248-1946 or visit http://qualitypress.asq.org/ (ISBN 1556481322).