Case Management, is recognized as an important tool in both the promotion of optimum client health outcomes and in reducing the costs of care. Tension and potential conflict can exist between these case management functions. Indeed the definitions of Case Management embody this tension.
·“…..a client centered service that enables people and their caregivers to achieve and maintain their highest level of functioning and independence consistent with their values, priorities, capacities, and preferences for care.
·An ongoing assessment process and the collaborative identification of changing needs and optimum outcomes facilitate the achievement of this goal.
·A practice that ensures the fiscally responsible use of appropriate resources to achieve the desired outcomes by mobilizing and integrating formal and informal support networks.”
The reality of this tension means that the Case Manager, who oversees, coordinates and integrates care delivery, must possess the appropriate knowledge, skill, expertise and judgment to recognize the tension and act to ensure that high quality care is provided to those who need it, where and when they need it.
Despite the increasingly complex care needs of many patients, minimum qualifications and professional requirements for case managers have not been established in Ontario. The need for safe effective care makes it essential that there be clarity regarding case management practice and minimum standards for those who are case managers. High quality patient care requires a case manager who recognizes and acknowledges the systems issues that impact the case management role.
RNAO has long advocated for appropriate access to professional nursing services, and has expressed concerns regarding the impact of less qualified caregivers on the health of patients. RNAO’s position is that Ontarians must have access to care from the most appropriate and best-qualified care provider. It is the position of the Registered Nurses Association of Ontario (RNAO) that registered nurses are ideal Case Managers.
RNs possess a broad nursing knowledge base that includes human/medical sciences, psychology, sociology, administration, and health care economics. This enables the registered nurse to identify the multiple and complex biopsychosocial needs of those receiving care. In addition, the RN’s comprehensive view of health and understanding of the scope of other health care professionals facilitates the provision of integrated care that is both efficient and effective. This also enables registered nurses to design, coordinate, implement, and evaluate effective and cost efficient care.
Case Management as a Service - Background
Case Management originated at the turn of the century within the disciplines of public health nursing and social work to assist clients in making a smooth transition from one sector (typically the hospital) to another (usually the home). Case management involved coordinating services and resources to assist people in meeting their needs. Over time, case management expanded to include the provision of care to patients from a variety of sectors and with diverse needs such as those with acquired brain injury or multiple health and social problems.
The Registered Nurse as Case Manager: Quality of Care
Registered nurses bring to case management the experience and knowledge that is required for clinical decisions. The nursing process (assessment, planning, implementation, and evaluation) is an integral part of the case management process.
The increased complexity of care needs mandates greater coordination and continuity, and requires a strong grasp of patient care situations. A depth and breadth of knowledge in clinical issues is needed for sound decision making. Registered nurses, guided by the College of Nurses of Ontario’s Standards of Practice, are accountable to provide high quality client care.
The nursing scope of practice also includes health promotion. This focus on prevention and education is beneficial to the health of patients and families. The shift from an illness centered medical model to a focus on prevention and optimal health and well being makes registered nurses particularly suitable to the case management role.
The research skills of registered nurses include knowledge of best practices and the ability to apply relevant research findings to optimize clinical outcomes. The skill to integrate this information into a health and social plan for the patient is essential. In some settings this skill is essential to design and coordinate vocational care plans.
The Registered Nurse as Case Manager: System Effectiveness
Registered nurses have strong clinical and decision making skills that enable them to provide care to a wide range of patients and families, across the life cycle, in all states of health. Thus the case manager who is a registered nurse can effectively monitor client status in response to intervention and address these changes as necessary.
Case management requires the ability to match patient needs with resources. The demands of the health-care system require a sound knowledge of community resources and supports to facilitate access to services by patients and their families.
Increasingly acutely ill and complex clients are being supported in a multitude of complex settings where resources may be scarce and difficult to access. These clients are also more likely to experience rapid changes in their clinical presentations. This reality underscores the need for case managers who can think critically and exercise sound decision-making. This decision making is based on an in-depth, comprehensive knowledge of overall patient needs, experience, a holistic perspective, use of appropriate strategies and the resources available to address client needs. This includes the need to interpret disease processes and related changes, promote wellness and engage in focused health promotion in providing care to patients and families.
The climate of cost control and rationed resources can negatively impact client care, particularly for vulnerable populations. In facing the challenge of simultaneously advocating for the client and being stewards of organizational resource, the case manager must be accountable first and foremost to the clients they serve. To that end case managers have a responsibility to advocate for fundamental change at the systems or organizational level to meet patient needs.
Case management does not replace the coordination, care and treatment provided by other team members, including registered nurses in their practices. Rather, case management reflects a collaborative process with clinical nursing and multidisciplinary team members to maximize system effectiveness. The RN case manager can effectively collaborate with all members of the interdisciplinary team to avoid duplication of service. The collaboration process involves assessment, planning, implementation, coordination, monitoring, and evaluation of the options and services needed. It may also include involvement in vocational, employment, and social rehabilitation counseling.
Case management service, delivered by a regulated professional such as a registered nurse, is paramount as our health care system changes and the needs of those receiving care becomes increasingly complex. For reasons of health care effectiveness and optimal client outcomes, Ontarians need the assurance of a regulated professional to fulfill this critical function. Among regulated professionals, registered nurses are ideal case managers for their ability to meet the needs of complex clients throughout the life cycle.
Please see the PDF version of this document  for footnotes and references.