Data-Driven Case Managegment: An Important Part of Population Health

by Alan Cudney, RN-BC, CPHQ, PMP, FACHE Mr. Cudney is President, HealthCare Impact, LLC and an associate member of the PhoenixMed team.
Published on Oct 09, 2015

Achieving value-based care is nearly impossible without an effective case management program. As we approach the 2015 National Case Management Week, October 11-17, please take time to learn more and embrace the contribution of case management.


Interest in value-based care and population health management has reached a fever pitch as legislators, care delivery organizations and payers decide how to meet increasing demands with limited healthcare resources. The Institute for Healthcare Improvement (IHI) summarized this conundrum in the Triple Aim, which includes the goals of improving patient experience of care (including quality and satisfaction), improving the health of populations and reducing the per capita cost of care.1 Now, Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) are helping to embody these aims, supported by an abundance of government incentives and demonstration projects. Both of these organizational models support population health management and include two important components.


The first is clinical data that is actionable in the form of reports and automated rules. These are best generated from computer applications that “talk to each other” and are able to synthesize data, helping providers and case managers work more efficiently to focus on achieving important clinical outcomes. As suggested by Dr. Richard Hodach in Provider-Led Population Health Management, these data can be used to generate automated reminders and messaging to encourage healthy behaviors and self-care to those in the population who do not yet need direct intervention by a clinician or caregiver.2


The other element is the professional discipline of Case Management, which many refer to as care coordination or care management. Just as the challenges in managing population health have deep roots, the mission and focus of case management are critical to achieving the Triple Aim. Case management has been practiced for decades, even before it had a formal name. The term case management became familiar during the 1980s as acute care hospitals and health systems began to feel the impact of Medicare’s Prospective Payment System. One of the most commonly accepted definitions of case management is:
“Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes.”3

Case management is practiced in acute-care hospitals, long-term care facilities, health plans, multispecialty practices, rehabilitation hospitals and a host of other healthcare financing and delivery entities. The basic principles and concepts of case management are similar across all settings of care, although their points of emphasis may differ. For example:

  •  In hospitals, case managers promote care progression and discharge planning, while ensuring appropriate documentation and compliance to support payer reimbursement for the care provided
  • At health plans, case managers coordinate health services for complex patients across the continuum of care to help the insured patient achieve the best utilization of benefits and assist the health plan in containing medical costs
  • As part of ACOs, case managers ensure high quality and well-coordinated health care services that result in improvements to the overall health of a population served, while controlling the growth rate of expenses

At its heart, case management expresses the concept of population health and continues to play an important part in the era of healthcare reform. Case managers, armed with the right data and technology, can have tremendous impact on fulfilling the Triple Aim. In a previous publication, this author wrote:

"Case management has the ability to significantly and profoundly affect not only patient safety and quality of care but also the viability of the health system. Case management, as a strategic priority, deserves serious consideration, responsibility, and accountability in the contemporary health system. Leaders need to realize that the potential impact from an effective case management program will only flourish with their support.”4

So what are key drivers of success for an effective case management program? Consider how much these describe your situation:

  •  Explicit support from leaders who understand the strategic value of case management
  •  Continuous use of analytics to focus efforts, understand outcomes and improve performance
  •  Workflows that use information technology effectively and efficiently across the continuum of care
  •  Collaborative approaches that consider the role and perspective of each member of the care team
  •  Intentional strategies for engaging individuals and families to promote health maintenance and improvement
  •  Consistency with evidence-based clinical practice
  • Coordination between case management programs of different organizations for occasions when they share responsibility for the same patients

Achieving value-based care is nearly impossible without an effective case management program. As we approach the 2015 National Case Management Week, October 11-17, please take time to learn more and embrace the contribution of case management.

1 Accessed at www.IHI.org
2 Hodach, Richard, MD, MPH, PhD. Provider-Led Population Health Management. AuthorHouse, 2015.
Case Management Society of America. Accessed at http://www.cmsa.org/Home/CMSA/WhatisaCaseManager/tabid/224/Default.aspx
4 Cudney, Alan E. "Case Management: A serious Solution for Serious Issues" J of Healthcare Management Vol. 47, No.3, May/June 2002, Pp. 149-152.