Case Management (USA Health System) - Hospital Case Management

Hospital Case Management

The American Case Management Association (ACMA), a non-profit professional membership organization supporting the practice of hospital case management through education, networking, publications, benchmarking and research, defines Hospital/Health System Case Management as:

“…A collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The Case Management process encompasses communication and facilitates care along a continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient's right to self determination."

Hospital Case Managers are professionals in the hospital setting who ensure that patients are admitted and transitioned to the appropriate level of care, have an effective plan of care and are receiving prescribed treatment, and have an advocate for services and plans needed during and after their stay. Case Managers concurrently plan for transitions of care, discharge and often post discharge follow up. Case Managers often coordinate/communicate with the patient and family, physician(s), funding sources (i.e. insurance, Medicare), and community resources that provide services the patient may need, such as rehabilitation facilities or providers of medical equipment. Through this coordination, hospital case managers’ goals are to ensure both optimal patient and hospital outcomes including quality of care, efficient resource utilization and reimbursement for services. Hospital Case Management is a collaborative practice, consisting primarily of Nurse and Social Work professionals working in collaboration with physicians and other members of the healthcare team.

Case Managers’ Role

A Case Manager’s responsibilities include the following functions:

•Advocacy & Education – ensuring the patient has an advocate for needed services and any needed education.

•Clinical Care Coordination/Facilitation – coordinating multiple aspects of care to ensure the patient progresses.

•Continuity/Transition Management – transitioning of the patient to the appropriate level of care needed.

•Utilization/Financial Management – managing resource utilization and reimbursement for services.

•Performance & Outcomes Management – monitoring, and if needed, intervening to achieve desired goals and outcomes for both the patient and the hospital.

•Psychosocial Management – assessing and addressing psychosocial needs including individual, familial, environmental, etc.

•Research & Practice Development – Identifying practice improvements and using evidence based data to influence needed practice changes .

Hospital Case Manager Education and Certification

To be a Case Manager requires experience in the hospital setting, typically as a nurse or a social worker. Additional skills specific to case management are learned in the role. Advanced certification is available to Hospital Case Managers through the Accredited Case Manager (ACM) Certification, offered by ACMA. The ACM Certification is the only certification that is specifically designed to validate an individual’s competency in hospital case management practice, and is offered to both Nurse and Social Work Case Managers.

The ACM Certification requires professionals to apply, demonstrate two years of hospital case management experience and licensure as a nurse or social worker, and to sit for and pass an examination. The exam consists of two components. The first section contains core case management questions that test the knowledge of Case Managers working in a hospital/health system. The second component consists of clinical simulations, which test the application of case management knowledge to simulated practice scenarios. Successful completion of the ACM Certification requires passing both parts of the exam, and earns the successful application the ACM credential. This credential must be renewed every four years through demonstrating the required hours of continuing education.

American Case Management Association

ACMA is the association solely for Hospital Case Management professionals, and currently consists of more than 2,000 members, and is represented by 18 state chapters nationwide. ACMA provides hospital-focused education and networking for Case Managers – including nurses, social workers, physicians, administrators and other health care professionals.