The effectiveness and efficiency of case management have been proven

The Case Management (CM) approach is currently a much-discussed progress program in the human services sector. Can the self-imposed claim that the approach promises not only effectiveness but efficiency and that it can also be used by very different professions be fulfilled? Using the example of the Bosch BKK study carried out by the KFH-Mainz and the Center for Impact Research (CAW) Mainz, the implementation of CM is examined (Löcherbach et al. 2010): Effects of patient support are examined at the case level (effects and impacts). Organizational level (costs) and the network level (doctors, hospital social services) were examined based on data from 1064 patients and more than 300 cooperation partners. In order to demonstrate the effects of CM, a quasi-experimental control group design was chosen and follow-up and outcome data were compared over a longer period of time (up to 14 months after completion of the intervention).

>> Why the CM approach? There has been over 15 years of experience with case management in the social, health and insurance sectors in Germany: CM, according to the theory, helps to initiate individually tailored and rationally justifiable human services across sectors and disciplines. Politically, the action concept is recommended in reform processes for solutions for targeted, coordinated and integrated care that is accountable and billable and geared towards user participation. That is why it was incorporated into new legal regulations for the individual service areas of the SGB - from basic security to statutory health insurance and rehabilitation in the event of disability to long-term care insurance. In healthcare in particular, CM as a procedure plays a key role in managed care because
• it stands for a coordinated disease- or patient-related approach on a case-by-case and case-group basis (service integration)
• Ensures mutual coordination of care activities and health/illness and care-related patient behavior
• In case management, an integrated system-based approach (continuum of care) is possible, particularly in the care of chronic patients.

The German Society for Care and Case Management eV (founded in 2005) has summarized the key points of the CM (DGCC 2008). They include: Case management is a special management task that is designed and understood as a cooperative process. It is always appropriate when a complex, long-term problem has to be managed, for which several actors, sometimes from very different supply systems, have to coordinate. For this purpose, service offerings with treatment, therapy and other services are collected, planned, implemented, coordinated, monitored and evaluated in order to cover the individual care needs of a recipient through communication and available resources. Control takes place at the individual level
• in approach, that is, in a theory-driven case selection based on data and experience
• in the breadth of the assessment, including medical, nursing, social and (social) legal diagnoses and assessments of needs
• in care planning and agreement, which coordinates the various service offerings and service providers
• in monitoring, which includes performance control through feedback systems
As a design method that is neutral towards the disciplines, it can be used across disciplines and sectors in the organization of care processes. Both in an inpatient context, as well as with a family doctor and in contexts of outpatient and home care.

The model of patient support
Patient support in a health insurance company (such as Bosch BKK) is a specific form of implementing CM.
1. Case level: The operational level of case management, in which BoschBKK refers to patient support, refers to the establishment and management of support networks and to collaboration with patients in individual cases. It takes place in the practice-oriented and flexible application of the procedure with the process steps defined above to cover the individually determined needs. Case managers ensure continuity of the intervention and bear professional responsibility towards the individual patients. Case-related, individual case management is carried out at the operational level. At least here, the acceptance of help depends heavily on the professional relationship between the case manager and the patient/relatives. As the study shows, patient support is all the more successful the better it is at negotiating needs defined by experts (e.g. treatment needs that specialists define) and the patient's respective ideas and wishes. The fit (balancing) of patient needs and care needs is a central mechanism of action: There has to be someone there who helps to get things in order, who takes the time to advise, weigh up, and coordinate the care situation ensures that patients understand things and processes to the extent that they do not feel taken advantage of or used. This special form is called “care counseling” in the CM and, in addition to comprehensive advice, also includes addressing fears and anxieties, discussing contradictions and encouraging people to exercise their rights as a patient. This also means providing assistance in coming to terms with difficult decisions or in making greater use of one's own options for improving health behavior. This takes time, in-depth knowledge and, above all, advisory skills. Particularly when the treatment measures require implementation into everyday life and integration into the patient's reality for long-term security. The study also shows that such patient support (carried out by health insurance employees) relieves the burden on other professional groups: doctors and social workers (in the hospital social service - KSD) see the greatest advantages in reducing bureaucracy, more effective coordination between those involved in the help and a better level of information for patients. Doctors also see a noticeable relief in the psychosocial care of patients.
2. Organizational level: CM requires appropriate organizational development (intra muros or extra muros). While individual case management clarifies what the case is and decides on how to manage the case (in coordination with the patient, in the assessment) and the case is thus the subject of joint processing, case management deals with all cases at the organizational level the facility (management of cases). The management of all cases in an organization (whether a hospital, nursing service or health insurance company) is carried out using process control and control methods. The organization ensures the simultaneous care of all patients within the care area according to their medical, social, nursing and (social) legal requirements. To do this, the organization uses its “standard programs”. In addition to the standard cases (problem constellations that can be solved with the existing programs and easily represented in the flow chart), every organization always has to deal with special problems, i.e. “special cases”. These are characterized by special features that are only inadequately reflected in the “paths” or the standardized procedures stored in the organizational concept and therefore often cannot be optimally addressed. The management of “special cases” now requires being able to identify them, recruit them for individual case management and then control them. The Bosch BKK has introduced CM as a “guiding principle”. This means that the control of measures and the process organization follow the CM concept: screening for case selection takes place. The subsequent processes are described (manual), the employees are qualified, the professional support of the patient support is ensured, the structural anchoring in the organization has taken place and the necessary instruments for case processing are standardized and largely computer-supported. In principle, a case- and case-group-related evaluation is possible. Management in individual cases (patient support) requires structural and procedural integration (access control) for case selection (case finding). Screening before the start of treatment is intended to identify patients who need intensive and cross-sector case support and to provide them with certain case management functions through delegation. Their classification is necessary so that the supply company can use its “production factors” appropriately and in accordance with the different legal and actual demands of users (Wendt 2009: 45). Screening therefore means distinguishing between CM cases (i.e. patients who are eligible for patient care) and non-CM cases (patients who receive “standard care”) based on certain criteria. The general criterion for CM cases should be a special need for support or help, which is characterized by a multidimensional problem complexity (illness-related, personal and social level), problems in access to care offers, possibly economic problems and, in particular, a high density of actors (see also Cesta et al. 1998, quoted in Ewers 2000, 74 f.). Data analyzes can enable the creation of a few screening criteria that lead to the identification of case management case constellations. The experience of Bosch BKK proves how relevant the process is for the development of a well-founded screening: In the study, four groups were formed using a computer-supported screening process (stroke, heart disease and cancer, and over 75): Three of the four study groups were relatively Definable diagnoses or diagnostic groups are formed. In the fourth, the over-75 group, additional selection criteria were applied in addition to age (over 75 years) (internal selection criteria that included several diagnostic groups and external ones, e.g. cooperation obligations). This was relevant to the design of the study. It has been shown that the selection criteria for the over-75 group were not sufficiently specific for a specialist assignment to patient support due to the heterogeneity of this group. This explains the comparatively poorer performance in the over 75 group. The remaining three groups are obviously more suitable for patient support. The evaluations presented, supplemented by the experiences of the patient companions and further (data) analyses, will enable Bosch BKK to refine the screening and systematically adapt the case groups in the future. If necessary, the existing selection groups can be expanded (e.g. to include certain chronic illnesses that require control, younger insured people, work with relatives). If an organization decides to introduce case management, the core processes (information, information, advice, supply management, crisis intervention, public relations, network development and control) and products must be defined. The patient groups for which case management is an option must be selected. The organizational anchoring and integration into quality management must be specified. For example, connection, (team and communication) structure, decision-making authority and technical control must be determined. The development of institute-related and cross-professional “spaces for shared learning” (e.g. teams, collegial advisory groups, quality circles, supervision) plays an important role.
It may come as a surprise, but the professional personnel question (who is a case manager or is involved in the CM?) is of secondary importance. What remains crucial in the CM process is that different specialists are involved and different qualification profiles are necessary. This requires conceptual work - “specialism” should not be combated, because specialists are particularly needed in complex case constellations: These are complex problems in which one cannot be expected to act alone or (as will be shown later: a organization/unit acting alone) solves it, but rather that the problem is solved in coordination with the coordinating authority of the CM. The CM in the organization requires networking internally and externally. These two processes can certainly be carried out by different employees, as the example of Bosch BKK shows: The competencies between patient companions (focus: patient work) and area representatives (focus: network work) are defined.
At the organizational level, the question arises as to what impact CM has on the (business) results. The study evaluated the available cost data (all identifiable patient costs with the exception of service expenditure for outpatient medical treatment) for 1,064 patients. It turns out that the model is initially associated with additional costs in the form of expenses for patient support and costs for optimized care, which change into positive cost effects on service expenditure after about a year at the latest. Overall, significant savings of an average of 21.5 percent were determined approximately one year after the end of patient support. A conservative “extrapolation” shows: With an average of 2,300 euros, the savings with 95 %iger security are in the range between approx. 900 euros and 3,700 euros and with 99 %iger security between 450 euros and 4,150 euros. The expenses for the medical contractual partners, for waiving the practice fee for enrolled patients and for the internal costs for patient support are offset by the savings and lead to the result: According to Bosch BKK, improving care does not involve any additional costs. Even if additional costs remain, for example in the sense of a full cost calculation (taking all investments and direct and indirect costs into account), the introduction of patient support for the health insurance company results in better care and care structure (primary goal of quality before secondary goal of cost savings) and thus an appropriate cost-savings. Benefit ratio (efficiency) that is entirely justifiable.
3. The integration of the case management organization into the regional assistance system: The integration links the management of the system-internal processes with the care external to the system. This is necessary for cross-case and cross-institutional control and network formation. Conceptual questions regarding the initiation of networks, the selection of network partners and the contractual structure of the cooperation must be clarified so that they serve the goal of optimizing networking. This shows how important the integration of network partners is: On what basis and with what benefits can the partners be integrated? What incentives are there for networking? Initiators are well advised to clarify these questions in advance. In the area of statutory health insurance, selective contracts can play an important role in the future. In the Bosch BKK study, patient support is part of contracts in accordance with Sections 73 and 140 SGB V with regional medical associations. It is crucial that doctors are informed about the model, receive a financial incentive to cooperate and are obliged to cooperate. This creates an essential basis for networking important cooperation partners. The system is still in the testing phase and requires adjustment. The incentive system can be tied even more closely to verifiable services (e.g. consulting services, cooperation services in a case, cooperation services in a group). In addition, there may be a contractual relationship with other (health) providers or service providers (e.g. hospital social services). Systematic networking with related and complementary (social) assistance as well as with existing networks in the respective region would be the next step. In the future, patient support could e.g. B. cooperate sensibly with care bases (if these are implemented).
Implications for care
Care counseling in case management combines meeting individual needs with care. CM can serve both as a personalized approach on the part of the service provider (insurance company) and on the side of the healthcare provider, or can be used as an intermediary
• for coordination in a network of doctors,
• in rehabilitation management
• in subsequent supply management (§ 11 SGB V)
• in the care base (here in the form of care management).

CM should not be viewed as an isolated service, but as part of a complex service. A complex need for help requires the supply system to offer a correspondingly diverse range of services. Case management, and this is where the circle closes, has the task of providing case-related integrated care by performing an interface function: from inpatient to outpatient care; from acute care to rehabilitation; from formal care to informal care work using the otherwise separate practitioners and service providers. Networking in a specific case is one thing (that of individual case management), networking for cross-case offer control is another (that of care management).
The cross-case system and care control is intended to create the structural requirements in the community for a specific target group in order to coordinate offers and strategies, for example for the care of people and their relatives, but also in open work. The transition to care management (perspective of care that goes beyond the regional perspective) becomes clear: incorrect care, undercare and overcare can be avoided. The Bosch BKK model shows exemplary approaches to medical/nursing care.
Case management is wanted and is politically supported. While the program is convincing at the operational level, there is a need for further development at the strategic and normative level. Case management promises effectiveness, efficiency and quality. This is often referred to. But the approach assumes that this takes place in and through coordination and cooperation - consensually. In contrast, financial incentives (budgeting or financing of treatment services) continue to favor individual interests, competitive thinking and short-term savings in the healthcare quasi-market. This, like the following contradiction, needs to be addressed: Politics (normative level) likes to refer to case management, but does little to overcome the structural barriers by demanding networking but providing little incentive for its development. The current example of care bases (SGB
Current results from model projects and research projects in Germany (and also in the mother countries of CM - the USA and Great Britain) support the following trend: the more (qualitative) case management elements are implemented at the individual case, organizational and system level, the more The results are better (cf. Schmid/Schu 2006, Mueser et al. 1998, Schleuning 2001, Thorenz 2006, Schmid et al. 2007, Porz et al. 2009). However, it is currently often left to the protagonists to prove the effects and cost-effectiveness of CM in their area of responsibility: The Bosch-BKK study shows that optimizing patient care is not necessarily associated with additional costs, but that the additional effort for CM, at least for the health insurance company, amortized after one year - due to increased efficiency. Overall, the results show that the patient support model largely achieved four goals:
1. Customer satisfaction
2. Effectiveness and quality improvement
3. Increased efficiency
4. Image gain and better system acceptance
The Bosch BKK shows how the implementation of patient support can be successful and how patient care can be optimized and focuses on medium and long-term financial effects. The study results confirm the chosen direction and provide information for further development, both within the health insurance company and with regard to the reorganization of the patient care system in general. Health policy remains called upon to provide clearer incentives through legislation and to effectively support this and other integrated forms of care. <<