Physicians, nurses, and other healthcare workers have all had to acknowledge the influence of finance on patient care. In an effort to work within the financial constraints that have been imposed, yet continue to deliver quality care, the concept of case management has evolved.

Defining case management may help to shape understanding of what it really is. Some confusion occurs with the term "managed care," partially because case management is based on similar ideas, but also because the two concepts rose in popularity at about the same time.

Managed care is a method of delivering health care that is focused on cost-effective, patient outcome-oriented concepts. It keeps costs under control and manages resources while continuing to strive for good quality in patient care. It encompasses the health maintenance organization, the preferred provider organization, and other methods of healthcare delivery [163].

Case management is a reorganized nursing structure that gives more responsibility and decision-making capacity to nurses. A nurse case manager follows all aspects of a patient's care and becomes more intensely involved in the creation of positive outcomes. A case manager may function in any number of settings, each of which will substantially differ in regards to daily operations. In each setting, however, the patient remains at the center of concern [163].

The hospital-based case manager is also called a "within the walls," or WTW, case manager. WTW case managers may deliver bedside nursing care for a small group of patients, or they may supervise the case management program. Whatever the assignment, the WTW case manager monitors adherence to critical pathways as well as cost- and time-effective delivery of care, with an emphasis on positive outcomes for the patient. Depending on the facility, nurse case managers may also complete discharge planning and utilization review functions [163].

Due to the nature of the disease, patients with lung cancer may have many hospitalizations. Having the same case manager for each admission helps patients feel a continuity of care that allays anxiety and promotes a more effective therapeutic relationship. The following case study and discussion illustrate the role of case management in the care of a patient with lung cancer.

Patient H is a man, 60 years of age, who has been admitted twice previously to City Memorial Medical Center for treatment of his small cell lung cancer. Nurse S has been his WTW case manager each time. This admission, she greets Patient H like an old friend. She knows his history, family situation, and health insurance plan from past admissions, plus she has been kept informed regarding his status by telephone calls. Now, she has only to assess his current status and be apprised as to what has been happening to him recently. This not only reassures Patient H that he is in familiar and caring hands, but it eliminates the time required for Nurse S to learn about him.

WTW case managers not only start IVs and administer medications, they also check with radiology about the delay in chest film reports, call physicians with lab results, and ask dietitians to see patients about their weight loss. These interventions and others not only improve the quality of care, but decrease the length of stay, saving the hospital and insurance companies unnecessary expenses. The WTW case manager will also interface with other case managers.

Those who are employed outside the acute care hospital are called "beyond the walls," or BTW, case managers. The majority of working BTW case managers are employed by insurance companies or some sort of managed care group, but they may also be found in home healthcare agencies and other organizations [163]. It should be noted that some progressive hospitals have established BTW case managers to remain with patients after the patients have been discharged. These case managers do not provide hands-on care, but they do assess patients who have returned home and make referrals to home health or other agencies as necessary. This has proven to be cost-effective to hospitals by reducing the number of readmissions.

When Patient H was admitted to City Memorial, the information about his admission was transmitted from the admitting department to his insurance carrier, Western States Preferred Provider Organization (WSPPO). The particular policy, a PPO, reimburses at a better rate when those providers that are part of a network of hospitals, physicians, and other healthcare agencies listed in his provider directory are used. These providers have signed contracts with WSPPO to accept a lower reimbursement in exchange for the increased number of patients they will be receiving because of being included in the PPO provider directory.

Nurse M, a BTW case manager for Western States, contacted the hospital asking to speak with the patient's case manager, Nurse S. From this conversation, she garnered enough information about the patient's condition to authorize the insurance company to pay for the admission. She was able to determine that Patient H met the criteria established by WSPPO for admission to an acute care hospital.

Nurse S will not only be doing traditional nursing activities, but will provide the utilization review information to Nurse M. This reassures Patient H that his care is being paid for, and it allows Nurse S to maintain authorization for her patients.

As soon as a patient is admitted to the hospital, and perhaps before, if it was a scheduled admission, the WTW case manager will work with the patient and the patient's family to meet the discharge planning needs. A WTW case manager assesses the patient's physical, emotional, psychologic, and financial status. Then, using this assessment as a basis, he or she will identify potential needs for continued care posthospitalization. WTW case managers ask physicians, patients, and families many questions that will help them develop a discharge plan. Important discharge planning questions may include [164]:

After the discharge planning questions were answered, Nurse S began to formulate a plan for Patient H. Before the discharge plan could be put into effect, however, it had to be authorized by Nurse M at WSPPO. In order for referral to be made for durable medical equipment, home health care, or any other of a number of services, the authorization had to come from Nurse M.

One of the helpful aspects of BTW case management is the flexibility BTW case managers are given in an effort to control costs. As previously noted, WSPPO has contracts with specific providers (e.g., they have an agreement with a specific rental company to provide hospital beds to WSPPO patients for a discounted rate). This saves both Nurse M and Nurse S from searching for a hospital bed provider; they both know immediately that they must first check with the designated rental company.

BTW case managers may also take advantage of the substitution of benefits. This means that if a patient needs a hospital bed at home, but the patient's healthcare plan does not include a benefit provision for durable medical equipment, a bed may still be provided if it can be proven that the equipment would shorten the hospital stay. BTW case managers often have the authority to approve a bed as a method of controlling costs; it is less expensive for insurance providers to pay for a bed rental than to pay for an additional day or more of acute hospitalization.

Some third-party payers have developed programs for disease management. This is essentially case management with patient participation in the program based solely on their diagnosis. The patient may have asthma, diabetes, heart disease, acquired immunodeficiency syndrome (AIDS), cancer, or other major illness. The purpose of a disease management program is to teach patients methods to control their chronic illness, recognize possible complications so early intervention can be provided, and reduce costs from frequent hospitalizations and costly treatments [165].

Nurse W is the WTW nurse case manager at City Memorial Hospital. She is assigned to the Oncology Unit on the day shift. Nurse B is a BTW case manager working in the oncology disease management division of Western States Health Maintenance Organization. This case study will examine how each of the case managers works to help care for the patient with lung cancer.

Patient P is a white man, 58 years of age, who worked as a sales representative for a nationally known greeting card company. He traveled by car over a wide area and spent a great deal of his time driving and smoking. The patient was first seen at his primary care physician's office for a routine physical that his wife had insisted he schedule.

When Patient P met the physician for the first time in September, he denied any major complaints and stated that he was there to appease his wife. His medical history revealed no major illness or injuries, apart from an appendectomy at 14 years of age. He admitted he had smoked two packs of cigarettes every day for the last forty years.

When the office nurse observed a frequent, nonproductive cough, she questioned Patient P about it. The patient claimed it was simply a tickle in his throat that came about every spring due to an allergy to budding trees and flowers. Because it was no longer spring and the cough remained, the office nurse made a note for the physician to check into the cough when he examined the patient.

The physician found nothing remarkable on Patient P's physical examination, even though he listened to the patient's chest to assess the cough. As a precaution, however, he ordered a chest x-ray and some routine lab work.

Three days later, the results of the exams were returned. The chest film showed an infiltrate in the patient's right lower lobe. Laboratory work showed mild anemia with a hemoglobin of 10.0 and hematocrit of 31. The patient was contacted and asked to return to the office to discuss the findings.

The next day at the office, the physician explained the results and showed Patient P and his wife the x-rays. He said that while he suspected lung cancer, he hoped he was wrong. A definitive diagnosis required further testing. The physician ordered sputum for cytology, an MRI of the chest, and scheduled a bronchoscopy with biopsy for later in the week, contingent upon approval from the insurance company.

Nonetheless, Patient P and his wife were cheerful when they left the office. They were sure that the physician was wrong, but glad that he was being so thorough. Patient P also agreed that it was time to stop smoking and begin a healthier lifestyle.

Patient P was given instructions for collecting the sputum specimens. The Western States HMO utilization review office approved both the MRI and bronchoscopy as "urgent," which meant it was not routine, but also not an emergency. The diagnosis on the authorization request was possible lung cancer, so a copy was automatically routed to Nurse B in the oncology disease management division.

Three days later, Patient P, accompanied by his wife, went to the outpatient department at City Memorial, the contracted hospital for Western States HMO. Patient P had been NPO since midnight. Once out of his clothes and into a gown, Patient P was taken into the procedures suite for the bronchoscopy.

After the bronchoscopy was completed, the physician explained to Patient P's wife that everything appeared normal with the procedure, but he still wanted the MRI. After the MRI was completed, Patient P recovered from the procedure and sedation and was ready for discharge. Just before they left, the physician came back into the room with a frown on his face.

The MRI showed a peripheral lung tumor. Based on the lung scan, the physician believed the mass was likely cancer, but he also wished to get a consult from a thoracic surgeon and obtain a biopsy to determine exactly what they were dealing with.

The biopsy was scheduled for the following Wednesday, but on Sunday evening the patient's wife, sounding frantic, called the physician. She related that Patient P had had a seizure and that she had called the paramedics. By the time the ambulance had arrived, her husband was awake and had refused to go with them. The paramedics insisted that the family physician be contacted immediately. Per the physician's instructions, Patient P was driven to the emergency room at City Memorial where he was examined and admitted to the Oncology Unit.

Monday morning, when Nurse W arrived on duty, she found she had a new patient, Patient P, who carried the diagnosis of probable adenocarcinoma of the right lung with brain metastasis. At their initial meeting, she noted that he was 6 feet 2 inches tall, weighed 220 pounds, and seemed physically fit. He was awake and cheerful. He told Nurse W that he had a spot on his lung but that he was here now because he had "some sort of freak seizure or something." He thought it was due either to the medication he had taken for the bronchoscopy or perhaps just stress. He repeated several times that he believed he was fine. The patient also expressed a need to get everything settled so he could concentrate on the impending birth of his first grandchild, who was due to be born in December.

Shortly after their conversation, a transporter arrived to take Patient P to the imaging department for a MRI of the brain. While having the procedure, Patient P suffered another tonic-clonic seizure. That afternoon, the physician, accompanied by Nurse W, went to the patient's room to speak with him and his wife. The physician related the findings of the brain MRI, which showed several areas in the brain that appeared to be metastases. He also emphasized the need to begin medication and radiation treatments. First, Patient P would be referred to a neurosurgeon for further examination and possible surgical intervention.

When Patient P's wife asked about the lung tumor, the physician stated that the first priority for treatment would be the brain metastases. The neurosurgeon would determine whether a biopsy would be necessary.

After having the physician write specific orders on the patient's chart, Nurse W returned to Patient P's room. She found both the patient and his wife smiling and upbeat. Patient P's wife expressed relief that they did not need to worry about the patient's lung tumor and stated that they would be happy when the neurosurgeon had Patient P's epilepsy under control.

Unsure whether the couple was in total denial or simply had misunderstood what the physician had said, Nurse W attempted to explain the physician's recommendations. She clarified that the physician did not say he had found epilepsy. She also asked the couple if they knew what metastasis was. The couple looked confused and Patient P shook his head.

Nurse W explained that metastasis occurs when a tumor from one place in the body, for example the lung, sends out cells that grow in another part of the body, such as the brain. She also elaborated that the physician believed that the abnormalities in the brain were caused by Patient P's lung cancer. Although it was confusing to the couple that the physician stated that they would not be treating the lung tumor, Nurse W emphasized that they would still be treating the cancer; the brain metastasis was just considered a more urgent matter.

Patient P sat stunned through the entire conversation. When Nurse W returned to the nurses' station, she noted the variances on the clinical pathway for lung cancer. Patient P was not following the path at all, but his variances were not due to mistakes or omissions; they were due to a changing clinical status.

The neurosurgeon saw Patient P later in the day and scheduled a biopsy of the brain using stereotactic surgery for Tuesday, the next day. Results from the biopsy confirmed metastatic adenocarcinoma from the lung.

Patient P was discharged from the hospital two days later. Before leaving, the physician spoke with the patient and his wife regarding immediate plans. He told them that there was no way Patient P could return to work. The physician stated that he would fill out the forms to declare the patient disabled for Social Security and that he wanted them to proceed with the forms the applicant needed to fill out.

Nurse W had extensive conversations with the couple to assess their home situation. She discovered that the patient's wife was no longer able to drive due to a visual problem, and now, because of the seizure disorder, Patient P could not either. She contacted the local branch of the American Cancer Society, where a volunteer arranged for daily transportation to the hospital outpatient department where the patient would receive his chemotherapy and radiation treatments. The supermarket and pharmacy were only one block from the couple's home, so they were able to walk there, and their two married children volunteered to help with other shopping on the weekends when they were available.

There did not seem to be a need for any durable medical equipment. Nurse B called Nurse W daily during the hospital admission to collect information to authorize the stay and also to begin to obtain baseline data for the oncology case management program.

The day after Patient P returned home, Nurse B called the house and spoke with him on the telephone. She explained who she was and that Western States was interested in having him participate in their oncology case management program. She told him that hopefully this would lead to fewer hospitalizations and a more supportive atmosphere during his illness.

Patient P agreed and asked Nurse B to explain everything to his wife, who also thought it sounded like a good program. By the end of the conversation, Nurse B had completed preliminary forms that recorded the best times to call and basic demographic information. She also set an appointment for a phone visit every Wednesday morning at 11 o'clock. During those calls she would complete questionnaires that were aimed at identifying signs and symptoms of possible complications or problems. It also gave her an opportunity to educate Patient P regarding lung cancer, brain metastasis, radiation therapy, chemotherapy, and other issues that presented. She gave Patient P and his wife her telephone number and asked them to call whenever they had questions or concerns.

Early on a Monday morning, two weeks into radiation, the patient's wife called Nurse B crying. She was concerned about her husband. He was sitting in his recliner watching sports on television all day. He said he was tired, but never would go to bed. He only left his chair to go for his treatment and to go to the bathroom. His wife had tried to talk with him about their future, but Patient P refused to answer. He was also eating poorly, and she believed he had lost weight.

Nurse B arranged to have a contracted home health agency send out a nurse for an assessment and then report back with the results. The home health nurse reported that Patient P weighed 208 pounds, a 12-pound loss since he had been in the hospital. He had sores in his mouth and seemed depressed. Nurse B then spoke again to both the patient and his wife on the telephone. She reinforced the oral hygiene measures that the home health nurse had shared with them and also spoke to them about measures to ease the mouth pain. She stressed the importance of adequate food and fluid intake and offered to send a dietitian to the home. They declined. Nurse B reported her findings to the patient's physician. Chemotherapy was ending, and the physician felt it probably was not advisable to begin another course.

A month later, Patient P was still in a decline. Still depressed, he was watching endless hours of television and eating poorly. His weight was now down to 196 pounds. His fatigue was a continued problem, and now he was having some shortness of breath, even at rest. At his doctor's appointment, arterial blood gases were drawn, and he was found to have a pO2 of 78 mm Hg. Home oxygen was ordered, which was arranged by Nurse B.

The next week when Nurse B called, she inquired about the status of the oxygen system. The patient was angry and asked when they were actually going to help him. He did not feel that he was getting adequate care. The patient's wife was also annoyed when she spoke to Nurse B. She was fed up with Patient P's bad attitude and said she was sick of being treated like hired help. She wondered why this had to happen to them. After speaking to the couple for several minutes, Nurse B could see they were both at the anger stage of grief. Frustration over Patient P's condition and an underlying fearfulness were apparent.

Nurse B was also concerned about the breathlessness that seemed to persist, despite the oxygen concentrator that was delivering oxygen at 2 liters per minute. She once again called the home health agency, which arranged for an initial assessment, followed by twice weekly nurse visits. The home health nurse recommended physical therapy to improve the patient's strength and endurance, as well as a hospital bed, as he refused to use his own bed. She felt that he liked the recliner because he could have his head up, which eased his respiratory effort. Nurse B approved both the physical therapy and the bed after consulting with the patient's physician.

Right before Thanksgiving, Patient P experienced marked swelling in his face and neck. The patient's wife contacted the physician, who authorized transport to the hospital for evaluation of possible superior vena cava syndrome.

After determining that the lung tumor had spread to the area blocking the flow through the superior vena cava, the physician, along with Nurse W, presented several options to Patient P, including surgery, more radiation and chemotherapy, or returning home with hospice to help with the final days.

The patient's wife was tearful, but said she wanted everything possible that could be done to save or prolong the patient's life. Patient P's demeanor had changed from the last time Nurse W had seen him. He was no longer upbeat, depressed or angry; he seemed tired, resigned, and at peace. He refused further treatment, stating that he wanted to go home for the holidays and enjoy his family. He had things he wanted to say to his children and he wanted to see his grandchild.

Nurse W stayed with the couple after the physician left the room. She reassured them both that if that was their choice, they would be given all the support and assistance they needed. Later, Nurse W spoke with Nurse B to obtain the needed authorization for hospice.

A hospice case manager came to the hospital and spoke with Patient P and his wife prior to discharge. She arranged for daily nurse visits to assess for pain control, respiratory problems, nutrition, and medications. She also spoke to them about advanced directives. Patient P told her that he had already signed a durable power of attorney for health care, appointing his wife as his spokesperson, and specifying that he wished to have no intubation or ventilator support. Both Nurse W and Nurse B followed the patient regularly by telephone. They answered questions and recommended nursing measures for problems that arose.

Christmas was a bittersweet time for Patient P's family. On December 21, his first grandchild, a girl, was born. She met her grandfather the next day and then spent a wonderful Christmas Day with the extended family. During the early morning of December 27, Patient P died as he slept. His wife was at his bedside, as was the hospice nurse.

Throughout this illness, the patient was kept informed of all the tests, treatments, procedures, and processes that occurred. Patient P was allowed to express his feelings, make choices, and exert some control over his life that had, in actuality, become very out-of-control. Because of this, he was better able to cope with the illness, his wife was better able to cope and to help him, and costs were kept to a minimum. Numerous hospitalizations were avoided and minor problems were prevented from escalating.