A Clarion Call for Case Managers

Like many readers of JGIM, I once spent many months going to a series of meetings to sketch out a critical path for congestive heart failure. At these meetings, I met our new case managers—two nurses, one with a public health degree and another with years of coronary care unit experience. Here was the plan: our interdisciplinary team of cardiologists, nutritionists, general internists, and others would write a detailed minute-by-minute description of the preferred therapy in our hospital. We were essentially locked in a room and forced to reach consensus on some knotty clinical challenges. Once this consensus was reached, we would enscribe it in the critical path and send our case managers forward to implement it. Our plan made sense and sounded as if it might work.

At the same time, articles were describing the new science of “case management”¹ and its sister field “disease management.”² An entire issue of one peer-reviewed journal featured case management.³ The American Hospital Association published a “how-to” guide for case managers that rapidly became a best-seller.⁴ A powerful new trend was in the making.

Our modest activities coupled with the burgeoning national literature convinced me that case management, disease management, and critical path implementation are all part of the struggle to limit unexplained clinical variation, introduce standardization, improve efficiency and quality, while lowering cost. This is a formidable challenge, and I am not sure that the current tools are up to the job.

It seems that Ferguson and Weinberger, writing in this issue of JGIM,⁵ agree. They define case management narrowly as “a program that uses physician or nonphysician providers to maintain continuous contact with patients via telephone or in home visits in order to prevent disease exacerbation through intensive assessment and education techniques.”⁵ Using this definition, they reviewed reports of randomized controlled trials to assess the impact of case management on health resource use, patient satisfaction, quality of life, functional status, and overall cost-effectiveness. They were able to document only modest progress. Indeed, of the seven studies meeting their inclusion criteria, only two found a positive effect, and both were focused on patients whose care was supervised by a medical specialist. They could not document any significant cost savings. Admittedly, some patient-centered outcomes like perceived quality of life and satisfaction were improved, but at an unknown cost.

This challenge by Ferguson and Weinberger needs to be addressed.⁵ Should we sacrifice the good on the altar of the perfect? We all agree that unexplained clinical variation limits our ability to promote accountability, improve quality, and lower costs. We are hungrily searching for the right tools to complete the job but are often limited to blunt instruments that do not fit the task at hand.

Perhaps we are looking at these tools the wrong way. Maybe the randomized control trial is simply too rigorous a methodology for a somewhat soft health services research question. Maybe we should accept that patient satisfaction, functional status, and perceived quality-of-life improved even though the investigators were unable to calculate specific cost savings and show a statistically significant decrease in resource use. Can we afford to wait for better data?

Personally, I believe we cannot wait for the definitive randomized controlled trial to determine whether case management works. Rather, we need to understand the etiology of case management more thoroughly, work to improve its current format, and appreciate the challenges that case management faces in the future. Let me tackle these themes in turn.

The need to standardize patient care in the face of unexplained clinical variation gave rise to case management. Standardization begat evidence–based guidelines, review criteria, and the construction of critical paths. Case managers were then needed to lead patients through the paths in our integrated delivery system of care. I realized how far matters have gone when I recently had the privilege of addressing the ninth annual meeting of the National Society of Medical Case Managers, which had 3,000 extremely enthusiastic attendees.⁶ Something is happening out there and we need to understand and evaluate it.

The real magic of case management, in my view, occurs in the meeting room where the interdisciplinary team struggles with creating day–to–day paths for patients. The construction of critical paths is itself an important quality improvement exercise because it brings together all those persons responsible for care to evaluate and improve that care. Using the technique of continuous quality improvement, the multidisciplinary team members share their own experiences and benchmark them against best practice inside and outside the organization. The tenor of the group discussion about congestive heart failure that I participated in months ago was friendly and, at times, provocative. I learned first-hand how persons in my own practice vary in their approach to essentially similar cases. We worked hard during these prolonged meetings to disassemble and reassemble our approach to congestive heart failure, with the overall goal of limiting unexplained clinical variation.

Yet, case management cannot work in a vacuum and needs to be a part of a larger activity focused on system–wide improvement in care delivery. Case management cannot work without better data systems, financial incentives that are aligned with quality goals, and most important, the ability to track any variance from critical paths and feed this information back to practitioners to close the loop on behavior change.⁷

Despite the findings in Ferguson and Weinberger's article,⁵ I believe the future of case management is assured if we can meet some key challenges. On a practical level, we must decide whether the critical path used by the case manager is a part of the medical record or not. Will it become a part of daily rounds, patient evaluation, morning report, and bedside teaching? Others have tried to make it a part of the clinical culture with a modicum of success.⁸ Also, we must reconcile the role of the general medicine attending physician with the role of case manager. I am aware that some of our colleagues bristle at the notion that they are no longer the sole manager of the clinical case, and we are rapidly surrendering autonomy to others with less training and expertise. Personally, I am willing to surrender some autonomy for greater public accountability as a survival strategy, but many of our colleagues are not equally motivated. Finally, where should case management be located in an organization like an academic medical center? Is it a nursing function or one that comes under the office of a medical director or vice president of medical affairs?

Ferguson and Weinberger did not examine the impact of the for-profit sector on case management.⁵ They cited the lack of published results by proprietary agencies who wish to use their successful technologies exclusively for their own gain. This is a narrow–minded approach because some firms are already partnering with academic medical centers to evaluate their technologies. I am convinced that we have much to learn from these firms and their new technologies, such as computerized protocols in hand–held palm–top computers and interactive voice–recognition equipment.

Careful readers of Ferguson and Weinberger will also note that the only successful programs they found were led by specialists and not general internists.⁵ This is a worrisome finding. If generalists abrogate their responsibilities in this arena because of other priorities, specialists might take over case management to maintain their hegemony and income level.

I have fond memories of working on an interdisciplinary team two years ago to craft a beautifully detailed critical path for patients with congestive heart failure. How we implement that path in our institution, track the variances, and measure its impact on care remains to be determined. It still makes sense to me. I hope it works.—David B. Nash, MD, MBA,Jefferson Medical College, Philadelphia, Pa.