As the year winds down, we often look back, then forward, before settling in the "now." If there is a single word that can accurately define this year, it is "change." We have all seen it and most have been profoundly affected by it, both personally and professionally. Inherent in "change" is the need to let go of one thing, person, health status, or way of doing things, in order for the something new (sometimes unwanted) to occur.

Case management has a life of its own. Those of us who have seen the trends, trials, and travels of case management will especially relate to these thoughts. In the May/June 2014 issue, Mindy Owen contributed the HeartBeat of Case Management department (Owen, 2014). It turned out to be one of the most discussed "HeartBeat" columns and, perhaps, hit a "nerve." But that is all part of trying out new ways of "doing." Some will be successful, some will be unsuccessful, and the rest will lie somewhere in between-where improvements can be made, but maybe with adjustments. Hospital case management is one such "experiment." Yes, some of the changes are necessary, others took a wrong path, and others seamlessly melded into what is known today as hospital case management.

Interestingly, some hospitals have downgraded the case manager role to one of utilization reviewer (UR), whereas other hospitals have separated the UR function entirely either keeping it under the case management program umbrella or moving it to finance. Some hospitals position the case manager in a social service capacity, providing counseling and complex discharge planning. And others find a middle road with a resource management component along with the more progressive case manager role of facilitating the patients' progression of care through the system efficiently and effectively.

The first group (the UR'ers) appears to be the most unsatisfied. Understandably! Where is the satisfaction in only doing that? Case management is more-much more. I have a problem with the alternative fork of the case management road simply because a social worker is professionally trained to handle some of the biggest problems our patients face: that role is best for the patient in those instances. The middle road is what Stefani Daniels writes about in her "letter." It is also an excellent history lesson of the early years of hospital case management. Before I copy Stefani's thoughts, I want to wish everyone a healthy, happy 2015. May all your "changes" be positive.

-Suzanne K. Powell, RN, MBA, CCM, CPHQ

I read your commentary in the May/June 2014 issue of Professional Case Management and felt compelled to respond in support of your call for redefining hospital case management. I have been on a personal crusade, as evidenced by many of my published articles, to bend the cultural track that hospital case management is following to return to our professional roots. I find myself as disillusioned as the proverbial Diogenes and seek to debunk the cultural conventions that have equated utilization review with case management.

Like you, those of us over 55 years remember the origin of hospital case management in the New England Medical Center (NEMC). I was a CNO at the time and started reading articles about the success NEMC had in transforming their nursing practice model into one that included the role of a nurse case manager who followed the patient from one area of the hospital to another with the goal of streamlining progression of care to reduce length of stay. At the time, length of stay was an easily obtained metric to gauge the success of efficiency. In my book and articles, I refer to this introduction of hospital case management as version 1.0-the clinical model. What's important to recall is that this nursing model change came about with the introduction of the prospective payment system into the hospital market. It was the changing marketplace that disrupted the status quo and the NEMC responded innovatively.

Not all hospitals responded as successfully as NEMC and when the revenue free-fall began in the late 80s, hundreds of hospitals closed because they could not adapt to the new market. Those that wanted to keep their doors open in the new marketplace reacted in the quickest way they knew ... consolidate and reduce full-time employees. And one of the easiest ways to do that was to merge hospital departments. As a result, social work and utilization review departments were brought together under the aegis of case management departments. Thus, we have version 2.0-the functional model, so called because the functions of the utilization review and social work department didn't change despite the new name. The practice of case management as originally practiced at NEMC was lost in the reengineering chaos at the time.

Hospital Case management Version 3.0 came about around the same time as the Institute of Medicine report, To Err Is Human, was published in 1999. The report inaugurated the call for dramatic improvement in hospital safety to reduce avoidable hospital deaths. Better patient care outcomes became the new marketplace demand and hospital case management leaders responded in kind. Hospitals moved to version 3.0 by slowing positioning the case manager as the primary stakeholder advocate working in partnership with the physician and care team to influence changes in practices and processes that affected the patient's movement across the episode of care. The function of utilization review was separated from the case manager role in many organizations and case management services were offered to those patients who would best benefit from having a "navigator" facilitating their safe, efficient, and effective progression of care yielding outcomes that objectively demonstrated the case managers' influence.

And now, we are in the throes of another shift in the marketplace, one brought on by the demand for greater value, better care coordination, and a healthier community. The Institute for Healthcare Improvement's Triple Aim best exemplifies the current marketplace: Health care that improves the experience of care, the quality of care, and the costs of care. So now hospital case management leaders are scrambling to meet the new marketplace demands and trying to figure out how to reinterpret inpatient concepts to patients as they travel beyond the walls of the hospital. Version 4.0 represents the next generation of case management. As one executive told me, "we are no longer in the hospital business, but in the community care business."

So, your question, "Going Forward: What Is Case Management," is quite relevant at this juncture. Hospital case management has reached another tipping point. Just as the marketplace drove the creation of v.2.0 and v.3.0, it is now driving the case for v.4.0. Hospital case managers who have been caught up in the utilization review and related coding and billing activities may not be prepared to shift to the new expectations. They may lack experience in how to engage the physician and the care team to ensure that the patient receives appropriate care and evidence-based care and coordinated to eliminate redundancies, delays, and gaps in the care continuum. This is not to say that knowledge of the "business" of managing the progression of care is not important ... indeed, a savvy hospital case manager is well prepared to counsel and coach the care team on the issues pertaining to the business of health and hospital care and how it may impact the patient's seamless continuum of care.

In my experience, hospital case managers have, for far too long, served as "enablers" to their workplace colleagues by taking on activities peripheral to their primary role. As long as program leaders and the executives who sponsor them lack clarity about the professional role of the case manager, this misuse of valuable resources will continue and hospital case managers will remain in the background as other more patient-centered practitioners take on the role of care coordination across the continuum. We are indeed at another tipping point and unless we go back to the future and take on our intended roles as a treatment plan coordinator, proactive advocate for safe, evidence-based, and cost-efficient care, and quality collaborator with members of the patients' entire care team, we will miss the opportunity to actively participate in the current transformation of our industry.

-Stefani Daniels, RN, MSNA, CMAC, ACM

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