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A new study of hospital-based case management reveals that nearly 74% of all hospitals in the United States now have some form of case management — a high figure, considering the paucity of case management departments only 10 years ago. Interestingly, however, the study’s author claims that her data challenge the conventional belief that hospital-based case management has grown in direct response to the expansion of managed care.
Indeed, the study found no significant relationship between case management implementation and the level of managed care penetration in local markets. "This was one of the most surprising findings in terms of prevalence of case management," says the study’s author, Jana Stonestreet, PhD, RN, chief nursing executive for Methodist Health Care System in San Antonio. "We’ve said for years that case management is a response to managed care, but the research doesn’t support that claim. You could speculate that hospitals are implementing case management due to the anticipated growth of managed care, but it would only be speculation."
Stonestreet mailed questionnaires to the chief nursing executives of 3,648 hospitals nationwide. She used a guide published by the American Hospital Association in Chicago to select general medical/surgical hospitals. "I chose the chief nursing executive as the most likely person to be able to answer questions related to the prevalence of case management in [her] hospital," she says.
More than 1,100 chief nursing executives returned Stonestreet’s survey, for a response rate of 32.6%. Of the 1,131 respondents, 73.7% said they had case management as defined by Stonestreet’s criteria.
Although the study found no relationship between managed care penetration and case management implementation, other factors do appear to have a significant relationship with the prevalence of case management in the acute setting. Those factors are:
• Bed size. 49.4% of hospitals with fewer than 50 beds reported having case management, compared with 97.9% for hospitals with 601 or more beds. "It was a stair-step relationship. The more beds the hospitals had, the more likely they were to have case management," Stonestreet notes.
• Ownership. 85% of for-profit hospitals reported having case management, compared with 71% of not-for-profit hospitals.
Of the 270 hospitals that reported not yet having case management, 57% reported plans to implement case management in the next one to 18 months, with five months as the most frequently cited time frame. "There were 31 hospitals who reported that they had implemented case management but discontinued their programs," says Stonestreet. "The most frequently cited reason for discontinuing case management was a lack of physician support."
Other reasons cited for discontinuing case management were inability to continue funding the case management program and inability to recruit qualified case managers.
"About 23% reported that they couldn’t find qualified case managers," Stonestreet notes. She also found that for-profit hospitals case-manage a larger percentage of their patients than not-for-profit hospitals do. "I found that on average, nationwide, about 72% of all inpatients are case-managed. In about one-third of hospitals, 100% of patients are being case-managed," she says. "That seems to go against the literature, which suggests case management is most effective when organizations target only their highest-cost, highest-use patients for case management services."
Only 10% of hospitals surveyed reported case-managing patients after discharge or in the outpatient setting. "The most frequent response by far was that hospitals case-manage none of their patients after discharge," she says.
Case management directors also queried
Stonestreet sent a follow-up survey addressed to the directors of case management of hospitals that reported implementing case management. The second survey included 49 questions related to the structure, process, and outcomes associated with case management in hospitals. She mailed 834 questionnaires, and 376 of them were returned, for a response rate of 45.1%.
Questions asked in the case management director survey include the following:
• What case management structures do you have in place?
• Is case management incorporated with other departments such as social work, or does it stand alone?
• Who is best qualified to do case management? (See related story, p. 144.)
• Who does the case manager report to?
• How are case managers assigned to patients?
• How are patients referred for case management?
• What tools do case managers use?
• What processes do case managers use?
• What information systems are used to support case management?
• What outcomes have case managers achieved?
Stonestreet plans to publish the data from the case management director survey in the near future. "When I was planning my dissertation, I found gaps in the literature. Most of the published studies reported the case management experience of individual hospitals. I found few studies that describe what exists today across segments of the population, and no studies describing what exists nationwide in acute care case management."
She says she hopes her work will form a foundation for other researchers to build on. "It’s as if, in case management, we skipped a preliminary step in the research. We jumped right to outcomes studies because there was administrative pressure to prove the effectiveness of case management," she says. "Yet if you scrutinize the studies in the literature, they don’t often describe who the case manager is or precisely what the intervention was. They provide little clear description of the roles and responsibilities of the case manager or the tools used to document their outcomes.
"I see my work as a broad overview of the current status of hospital case management," she says. "I think my high response rate indicates that people are very interested in this area of study. Another researcher might take a section of my data and focus in on [his or her] own interests. For example, I asked several questions about information systems used for case management. Another researcher may want take those responses and do a more focused study looking at information systems alone."