Case management is a managed care technique within the health care coverage system of the United States. It involves an integrated system that manages the delivery of comprehensive healthcare services for enrolled patients.^[1] Case managers are employed in almost every aspect of health care and these employ different approaches in the control of clinical actions.^[1]

The American Case Management Association (ACMA), a non-profit association dedicated to the support and development of the profession of case management through educational forums, networking opportunities, legislative advocacy and establishing the industry's Standards of Practice,^[2] defines case management as:^[3]

a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality cost effective outcomes.

Case management focuses on delivering personalized services to patients to improve their care, and involves four steps:

1. Referral of new patients (perhaps from another service if the client has relocated to a new area out of previous jurisdiction, or if client no longer meets the target of previous service, such as requiring a greater level of care). Alternatively, they may be referred after having been placed on an ITO or in an inpatient unit.
2. Planning & delivery of care
3. Evaluation of results for each patient & adjustment of the care plan
4. Evaluation of overall program effectiveness & adjustment of the program^[4]

In the context of a health insurer or health plan it is defined as:^[5]

A method of managing the provision of health care to members with high-cost medical conditions. The goal is to coordinate the care so as to both improve continuity and quality of care and lower costs.

Specific types of case management programs include catastrophic or large claim management programs, maternity case management programs, and transitional care management programs.^[4]

There are several models of case management and the distinctions are based on internal and external influences that have bearing on the level of success and differences in outcomes. These, for instance, include local influences such as the response to cost by funders of care and consumer pressure.^[1] The generic model used in the United States is the chronic care model, which holds that health care does not only involve change in the patient and that high-quality disease care counts the community, the health system, self-management support, delivery system design, decision support, and clinical information systems as important elements in the practice of case management.^[6] There is also the group decision-making models such as the rational model, which focuses on economic perspectives and maximum utility; and, the garbage can model, an approach based on difficult problem identification and solutions under uncertain circumstances.^[7] Other models also prioritize ethics such as the distributive justice model developed by Beauchamp and Childress of the Kennedy Institute of Ethics, where ethics a component of the case manager's responsibilities and is concerned with the distribution of finite resources for the benefit of an entire community.^[8]

The Certified Case Manager (CCM) credential is available to health care providers licensed to practice independently in the American health care system. For example, the license would be available to Registered Nurses but not Licensed Practical Nurses, who are not licensed to assess and evaluate the health of their clients.

The American Case Management Association (ACMA), a non-profit professional membership organization supporting the practice of hospital case management through education, networking, publications, bench-marking 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 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 management (mental health)
• Managed care
• Medical case management
• Nursing process
• Primary care case management
• Utilization management