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Care Coordination and Utilization Review: Clinical Case Managers’ Perceptions of Dual Role Obligations

Third-party payers continue to pressure hospitals to hold the line on escalating costs by employing utilization review strategies—such as reducing the average length of a patient’s stay—even though patients in the hospital are, on average, more severely ill than they were in the past. As a result, clinical case management is an increasingly important tool in the coordination of hospital care, and the role of the clinical case manager (CCM) continues to endure, grow, and evolve. Case management is a process by which the health needs of patients are assessed and their care is planned, implemented, monitored, and reassessed. The goal is to minimize the fragmentation and duplication of services by coordinating and integrating health and social service systems—to provide the best possible outcomes, within given fiscal and resource constraints. The individuals who usually receive care management services include those likely to incur high costs or with complex medical and psychosocial needs, and the socially disadvantaged. There are now several models of case management, since its rise in popularity in the mid-1980s, including nursing case management models. While studies have indicated that case management can decrease costs and improve patients’ outcomes, little research has focused on how CCMs in hospitals, who are usually nurses, experience their dual roles: the coordination of care and utilization review. What is it like for nurses, who traditionally view themselves as patient advocates, to take on roles that include tracking the acute healthcare needs of hospitalized patients, as well as overseeing the use of insurance and other resources? To answer this question, we sought to explore the perceptions and experiences of nurse CCMs in a tertiary acute care hospital.