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Introduction   

Nurse case managers, as the name implies, are nurses who manage many aspects of patient care. They wear multiple hats to meet the needs of their patients. Case managers can be evaluators, assessors, liaisons, schedulers, and educators, and can provide direct care to patients. They are typically the contact person in the eyes of their patient. This is no easy task. Being the point person in healthcare requires exceptional organizational skills, effective time management, and care coordination.  

Case management is an important part of palliative and hospice care. Hospice patients, for example, have complex care needs at the end of life and depend on their nurse case manager to do things like provide symptom relief, formulate care plans, maintain communication with other disciplines, schedule appointments, and provide education on end-of-life care. Regardless of the setting, it has become clear that case managers play an integral role in decreasing hospital utilization rates and allowing patients to live more fulfilled lives.  

Nurses interested in becoming case managers should know the required educational background, work experience, services provided, and overall duties of the profession to successfully be hired as a case manager. 

History of Case Management 

Case management has evolved over time and has a strong history in the United States. Case management originated in the U.S. in 1950-1960 (1). Initially, case management was utilized in mental health cases. It was later used for high-risk patients and cases that involved high costs. The case manager role was born out of a need to improve efficiency and decrease variability.  

Case management is modeled after E. Wagner’s Chronic Care Model. This model includes the following elements needed to manage chronic diseases: the health system, clinical information systems, patient decision support, patient self-management, delivery system design, and the community. The main goal is that patients will be able to handle their disease with the elements. This means that patients are active and informed throughout the clinical relationship. This also tends to yield a high degree of satisfaction among patients and their families. 

It should also be noted that the concept of case management is not limited to nursing. Other disciplines can perform as case managers. Social workers, doctors, physical therapists, occupational therapists, and pharmacists also work as case managers. Typically, nurses will function as case managers due to their aptitude to assess, plan, and promote self-care. Due to its many successes, the role of the nurse case manager is now an emerging profession worldwide. 

(1). 

Case Manager Role 

Job Functions 

Nurse case managers play a vital role for their patients. They are the go-to people when it comes to managing their disease process. “The case manager is a clinician expert in coordinating care pathways, who takes into account the specific needs of an individual, in a cost-effective way” (2). Working as a case manager can be very complex. Not only does the work include managing health needs, but social needs as well. 

 “The case” being managed by the nurse case manager is not predictable from patient to patient. It involves the patient, family, other clinicians, medication management, etc. The nurse assumes the role of advocate and educator. They meet the needs of their patients with assessment, coordination, planning, and evaluating potential options (3). These healthcare professionals help reach goals such as improved patient care experiences, healthcare cost reduction, and improved population health.  

Nurse case managers can work in a variety of settings. These include hospitals, residential care settings, outpatient facilities, home health, hospice, and palliative care. Case management in the community allows nurses to serve patients who may be chronically ill, and that otherwise would not have regular access to healthcare. 

Education and Certifications Needed 

The role of the nurse case manager is ever evolving. It adapts as needed and this is apparent in the educational attainments held by nurse case managers throughout history. The first step in becoming a nurse case manager is to become a registered nurse (RN). There are various accredited programs, ADN, BSN, and MSN, for example, in which one can become a registered nurse. Successful completion of one of these programs would be followed by passing the NCLEX, which is the national nursing exam.  

Case management should be viewed as an advanced nursing specialty due to the number of professionals who hold a master’s degree or higher. 

In a 2020 study on educational backgrounds, (4) noted that 80.62% of respondents held a bachelor’s degree or higher. This was nearly a 10-percentage point gain from a 2014 study. Additionally, 14.55% held an associate degree, and 4.84% had a nursing diploma. The increase in advanced nursing degrees exemplifies the changing requirements for nurses working as case managers. This is a positive change and shows the continued move towards professionalization and the value that case managers have in the healthcare industry. 

Case management is not widely discussed in nursing school. Therefore, case managers do a lot of on-the-job learning to expand their knowledge. This is in addition to the various seminars and conferences that are available. 

Case managers can also become certified in case management. The Commission for Case Management Certification and The American Nurses Credentialing Center both provide this certification (7). Obtaining a certification in case management holds nurses to a higher standard and shows their commitment to the profession. 

Hospice and Palliative Care 

Both hospice and palliative care exist to comfort patients that are dying or seriously ill, and to support their families. These terms are often used interchangeably, but they serve different purposes. Palliative care is a broad term that describes an interdisciplinary approach to caring for both patients and their caregivers by supporting their physical, emotional, spiritual, and psychosocial needs (5).  

The key difference between palliative and hospice care lies in the timing of a patient’s illness. Palliative care, unlike hospice, can be utilized at any time during a major illness or complex disease process. Palliative care patients might also be seeking curative measures along with symptom management. Palliative care is useful in managing symptoms that negatively impact a person’s quality of life and supporting a patient who is treating a curable disease.  

Those receiving palliative care might exhibit decreased mobility, weight loss, oxygen dependence, and an overall worsening of their disease process. Common diseases warranting palliative care include cancer, COPD, and heart failure.  

Hospice is for patients that are approaching the end of their life. Hospice patients will likely have similar diagnoses as palliative care patients. The hospice is reserved for patients who have been certified by a doctor as being terminally ill (6). This means that their life expectancy is 6 months or less if the disease runs its expected course. Patients who elect hospice agree to comfort care rather than curative care. 

Overall, both palliative and hospice care are good options for patients that are needing symptom management. Both improve patient outcomes which leads to patient satisfaction and better experiences for both patients and their caregivers. In each specialty, nurse case managers are part of an interdisciplinary team that might include physicians, social workers, and chaplains. Ultimately, the nurse case manager is responsible for managing most aspects of care. Now let’s learn more about palliative and hospice nursing and how they are different from one another. 

The Hospice Nurse as Case Manager 

Although it takes a team of professionals from various backgrounds to fully meet the needs of hospice patients, the hospice nurse case manager is ultimately in charge of managing the “case”. The hospice nurse coordinates care with other disciplines and identifies social, psychological, spiritual, and physical needs (7).  

In addition to care coordination, hospice nurses perform many other services for their patients. This includes wound care, foley catheter care, managing ports and PICC lines, infusions, medication management, and much more. They care for the entire person physically, emotionally, and spiritually. 

Hospice nurses must also be skilled in talking about death and understanding the goals of care. Hospice nurses help patients, and their families navigate through an uncertain and unfamiliar time. Knowing things like advanced directives and medical power of attorney is essential. These documents are part of end-of-life planning and once completed, can help clarify what actions to take while a person is dying. Having end-of-life conversations is an important and common part of the job.  

Hospice nurses are special due to their ability to make challenging conversations easier for everyone involved. These difficult conversations may also involve breaking bad news such as informing a caregiver that a patient has begun to transition and may have days to live. Hospice case managers are crucial in end-of-life care and invaluable members of the hospice interdisciplinary team. 

The Palliative Nurse as Case Manager      

Palliative nurses are an integral part of a team of clinicians who provide care to patients. “Palliative care is known as a ‘holistic’ approach because it considers the ‘whole’ person and their support network just the illness and its symptoms. It usually involves a team of people that can include physicians, nurses, pharmacists, other allied health professionals, social workers, chaplains, or volunteers (10).  

Through various measures, palliative nurse case managers help their patients have a better quality of life. (7) notes that pharmacologic and nonpharmacologic means are utilized to address symptoms in palliative care. The plan of care may be curative, or comfort focused. Like hospice nurses, palliative nurses can work in a variety of settings including hospitals, clinics, and in the home setting.  

Palliative nurse case managers are tasked with managing symptoms such as pain, giving and managing medications, providing support, and providing education regarding their patient’s condition. Effective communication is a big part of being a palliative nurse.  

Nurses must be able to discuss topics such as disease trajectory, medications, and decline. They are also responsible for communicating with doctors about new medication orders and changes in condition. Unlike hospice nurses, palliative nurses are not as task oriented. This means they are not doing things like wound care and maintaining urinary catheters. Symptom management is the goal. 

Benefits of Nursing Case Management 

The idea of the Nurse Case Manager has somewhat evolved out of necessity. Increasing access to healthcare and providing services to complex patients are some of the main reasons why case management began and continues to grow. (8) noted that case management promotes increased coordination of healthcare services and allows wider access to healthcare for all populations.  

Nurses are the largest occupational class in the healthcare sector, and they make important contributions to case management. Nurse case managers help with the utilization of available resources, facilitate communication among healthcare providers, patients, and families, and advocate for their patients. 

Studies on case management have shown the benefits of reduced healthcare costs when case management is involved. Those with complex needs and who frequently utilize healthcare services might be a relatively small group of people, but they tend to account for high healthcare costs. “Their efforts often prove to be fruitless and may result in repetitive use of healthcare services in an uncoordinated way through frequent emergency department visits or hospitalizations. Therefore, the service offered for this population calls for integrated care across providers of all settings and sectors (9).  

Case management is a form of integrated care used to reduce fragmentation and maintain the continuity of care. This is especially important for patients who are discharged from the hospital who are at risk for readmission. Case management brings healthcare to patients in any setting. Case managers improve both clinical and social outcomes for their patients by addressing their needs and connecting patients with other services that they may need. 

Patients who had access to a nurse case manager reported having better communication with other health professionals, increased participation in improving their health and well-being, and improved healthcare transition (8). These findings point to increased patient satisfaction and a more positive healthcare experience. 

Lastly, nurse case managers formulate the care plan and ensure that it is followed correctly. Case managers are part of an interdisciplinary team. They are the leader of this team and are responsible for communicating with the other team members regarding changes and patient needs. Within their role, they plan, evaluate, implement, coordinate, and prioritize the needs of their patients.  

These actions lead to outcomes such as reduced emergency department visits and lower healthcare costs. With support from all involved professionals, case management programs can flourish and allow better outcomes for all involved. 

Conclusion

Nurses make great case managers due to their innate skills such as prioritizing, educating, evaluating, planning, and coordinating.  Case management is a great model of healthcare for those with serious and complex illnesses. Without the guidance and involvement of a nurse case manager, these complex patients would have high utilization rates of costly healthcare services, emergency department visits, and unnecessary hospital admissions. 

 These patients are often referred to either palliative or hospice care. In addition to being a member of an interdisciplinary team, nurses function as case managers within those specialties and manage all aspects of care. Palliative nurses focus on symptom management, exhibit great communication skills, and serve as educators for their patients.  

Hospice nurses not only help to alleviate symptoms, but they also address end-of-life issues with patients and their families. Studies have shown that when case managers are involved, patients and their families tend to have better outcomes and higher rates of overall satisfaction. With continued support, the nurse case manager role can continue to evolve and continue to make an important impact in healthcare. 

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