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Case Management was once a simple administrative matter--an insurance adjuster managing a workers' compensation claim. Today, case managers with nursing, social work, or vocational rehabilitation backgrounds work directly with physicians, hospitals, home health agencies, nursing homes, and other organizations. Case managers now coordinate the health care needs of patients with chronic conditions like asthma or diabetes and patients with catastrophic medical problems such as cancer or severe burns.

Design: Descriptive study., Objective: To describe and compare the medical services provided following work-related tetraplegic spinal cord injury (SCI)., Setting: Workers' compensation claims database., Methods: The administrative database of a workers' compensation provider was searched for work-related tetraplegia claims with dates of injury between 1 January 1989 and 31 December 1999. In total, 62 cases were identified and grouped by impairment category. Medical payment data were extracted and assigned to service categories., Results: Although the level of services was directly related to the severity of impairment, patterns were similar across categories; for example, the largest proportions of payments were associated with durable medical equipment (DME) and attendant care in each impairment category. DME, readmissions and attendant care services varied considerably from year to year and within impairment category. Payments for physician care and medications/supplies showed the least variation within impairment categories. Workers' compensation payments were similar to National Spinal Cord Injury Database (NSCID) payments for the first year following injury; however, in subsequent years, workers' compensation figures were much higher., Conclusions: Differences in annual medical payment and services by impairment category appear to be primarily due to variations in DME, attendant care and readmission. Payment differences in relation to National SCI figures may be related to better capture of payments by the workers' compensation administrative database. In addition, results suggest broader coverage by workers' compensation for medical services and items related to independent living.

With managed care's promise to reduce costs and improve quality waning, employers and health plans are exploring more targeted ways to control rapidly rising health costs. Disease management programs, which focus on patients with chronic conditions such as asthma and diabetes, are growing in popularity, according to findings from the Center for Studying Health System Change's (HSC) 2002-03 site visits to 12 nationally representative communities. In addition to condition-based disease management programs, some health plans and employers are using intensive case management services to coordinate care for high-risk patients with potentially costly and complex medical conditions. Despite high expectations, evidence of both disease management and case management programs' success in controlling costs and improving quality remains limited.

Objective: This study assessed trends in access to and use of behavioral health services for school-aged children in TennCare, Tennessee's Medicaid managed care program, between state fiscal years 1995 and 2000., Methods: Claims, encounter, and enrollment data from the Bureau of TennCare were used. The data analyzed were restricted to services and enrollment periods for children and adolescents between the ages of four and 17 years at the time of service or enrollment. Measures were calculated in four areas: overall access to behavioral health services, use of inpatient services, use of outpatient specialty treatment services, and use of supportive services like case management and medication management., Results: The number of youths who received a behavioral service increased by nearly 50 percent between state fiscal years 1995 and 2000. At the same time, the number of youths enrolled in TennCare increased by 19 percent. The annual access rate increased from 72.7 youths per 1000 enrollees to 91.7. However, the volume of services for children fell. Access rates were low relative to estimates of need in this population. The system made less use of inpatient services and relied more on outpatient services, particularly case management and medication management services., Conclusions: Children's access rates for behavioral health services improved even as the TennCare program expanded to cover more children. The system served more youths in part by reducing the volume of services for children receiving treatment and substituting more supportive services. Ongoing performance monitoring for policy making will require enhancements of data monitoring activities by the state.

Objectives: To determine current practice patterns in the surgical treatment of ureteropelvic junction obstruction in the United States and Canada., Methods: An e-mail survey was sent to 56 academic endourologists regarding the number of procedures performed in the previous year for ureteropelvic junction obstruction, factors considered in the choice of procedure, and whether community urologists in their area were performing laparoscopic pyeloplasty or endopyelotomy., Results: The response rate was 66% (37 of 56). More respondents were performing endopyelotomy (91%) than laparoscopic pyeloplasty (51%), and nearly one half were performing open pyeloplasty. The mean number of procedures performed by respondents in the previous year was 9.5 endopyelotomies, 4 laparoscopic pyeloplasties, and 2.5 open pyeloplasties. A number of factors had an impact on the practitioners' choice of procedure, including the presence of a crossing vessel and massive hydronephrosis, secondary ureteropelvic junction obstruction, the surgeon's training, procedure cost, operative time, expected success rate, degree of invasiveness, and patient preference. Nearly one fifth of respondents said they would choose laparoscopic pyeloplasty as first-line therapy regardless of anatomic considerations. Seventy-eight percent stated that community urologists in their area were performing endopyelotomy routinely or occasionally compared with only 3% who stated community urologists in their area were performing laparoscopic pyeloplasty., Conclusions: Laparoscopic pyeloplasty is still in its early stages. Although laparoscopic pyeloplasty has a greater success rate, endopyelotomy continues to be more commonly performed in academic centers. Laparoscopic pyeloplasty has not yet made significant inroads into community practice. Several factors, especially the surgeons' training, have an impact on the choice of procedure. Open pyeloplasty is still performed by a significant number of academic endourologists.

An estimated 85% of infertility treatment at the tertiary level in the UK currently is funded by the infertile couples themselves. Of the 15% of couples who receive NHS funding for assisted reproductive technology (ART), a sizeable proportion is provided by private clinics. If the National Institute of Clinical Excellence (NICE) decides that the National Health Service (NHS) should provide funding for an increased number of treatments, then it is unlikely that wholly NHS ART clinics will be able to provide the extra number of cycles required. Those private clinics in the UK that bid to provide treatment funded by the NHS through primary care trusts (PCT) generally provide a cost-effective service in a 'patient friendly' environment. The case is made in this article that ART clinics in the private sector that wish to bid for PCT contracts, should be allowed to compete on an equal basis with NHS or NHS-private combined clinics. PCTs awarding contracts should be wholly driven by good evidence of clinical effectiveness, cost effectiveness and the provision of a quality service to patients.

Hospital-based infertility management will alter radically over the next few years. The forthcoming National Institute for Clinical Excellence guidelines should improve financial support for couples having National Health Service (NHS) assisted conception treatment, and increasing NHS interest in clinical governance may well lead to policy on issues such as number of embryos transferred, risk of ovarian hyperstimulation and patient selection for treatment. Changes in clinical practice will follow. In addition, a number of alterations to clinical training in reproductive medicine will soon be in place, with impact on both sub-specialist and specialist registrar training. It is also clear that private sector practice in general, and private facility assisted conception in particular will be more tightly regulated in the coming years, with increasing governance in both research and clinical practice.

Old French recommendations were to treat all pharyngitis cases to prevent acute rheumatic fever. 85 to 90% of cases were treated (8 to 9 millions/year), of which 3/4 unnecessary. Furthermore, penicillin V the drug of first choice was prescribed only to 5 to 10% of patients. Considering the preocupating increase of bacterial resistances and the disponibility of performane Group A Beta-Hemolytic Streptococcus Rapid Diagnostic Test (Negative Predictive Value above 95%), the new management strategy is proposed in two ways. Firstly, the free delivery of RDT to practitioners which was associated in Burgundy with a dramatic prescription decrease to 41% without benefice lost for patients. Considering these good results the French authorities decided the generalization of RDT use in 2002 and more than 15,000 practitioners have been concerned by the formations delivered in 3 months. Secondly, the short course treatment assays initiated by our group have been validated and since 2002 the AFSSAPS recommend the preferential use of compounds which obtained the authorization of use in short course with a new indication incitating to document GABHS pharyngitis by the RDT use.

For a long time, patients with liver metastases from colorectal cancer were considered to be incurable. Over the last 30 years, the benefits of surgical resection and systemic chemotherapy have been established. To date, surgical resection remains the only treatment that can ensure long-term survival and cure in some patient. However, only a minority of patients with liver metastases are amenable to surgery and after resection of liver metastases, recurrences are still observed in two third of patients. Therefore, efforts have been made to increase the number of patients that could be candidates for surgery and to decrease the risk of recurrence after surgical resection. Shrinkage of tumours after administration of pre-operative chemotherapy and the availability of new surgical technique, including portal vein embolization, cryotherapy and radiofrequency ablation, now allows the treatment, with curative intent, of metastases initially considered as non-resectable. Chemotherapy regimens have been developed to decrease the risk of postoperative recurrence.

This paper aims to assess current interventions in psychiatric rehabilitation in the French-speaking world and to discuss future developments. We review examples of policies and practices in Quebec and Europe and discuss the role and involvement of professionals; namely, the psychiatrists and the nursing staff. We also present different rehabilitation strategies and techniques used in the French-speaking world, such as case management, social-skills training, cognitive therapies for psychotic symptoms, family interventions, and return-to-work interventions. In conclusion, we invite psychiatrists to play a more active role in rehabilitation. We recommend the creation of small, specialized units closely linked to the needs of clients, and we propose to integrate social and medical interventions, rather than opposing them.

Case management, the basic process of matching key resources to individual's needs, often carried out across time and place, has been a relatively low-profile function (under various levels) within society, business, and health care for many years. Nurses have been involved in case management since its beginnings in social service and public health. However, nurses only became prominent as case managers during the last half of the 20th century because of the need to establish medical necessity for health care payments and, eventually, the need to provide discharge planning. The 21st century begins with an evolving core for case management functions in health care, the specific models dictated by the margins and missions of the employing organization. Case management, in fact, is the nursing process applied at a system level. However, if case management is to remain an adaptable yet powerful strategy for patients and organizations across the continuum of health care, it will have to move beyond access and medical necessity functions to those functions that demand advanced nursing experience and skills.

Case Management is a term that is present in almost every American health care situation. It is mostly used to coordinate community services with satisfactory results for the patient within a certain period of time, with limited resources. Through time, it has been used for different purposes. The goal of this study was to show the historical evolution of case management as expressed by the American nursing literature, in the 80's and 90's, according to its use, meaning, and application, and following a theoretical framework for concept analysis. The data was extracted from two journals: "Nursing Management" and "Journal of Nursing Administration". The publications showed case management portrayed as a process that serves a common goal; where quality and cost of care were the prevalent and influential elements along time, and its practice focusing in a given population defined as of high risk and high cost for health care.

Despite nearly 20 years of HIV prevention efforts, rates of new HIV infection persist at an alarming rate. As successful antiretroviral medications enable many HIV infected persons to live longer, healthier lives, interventions are necessary to support ongoing prevention and reduced risk behaviors. This article describes a survey that was used to assess the opportunities and challenges related to the integration of prevention screening into the work of HIV/AIDS case managers. The article describes the survey, reports the findings (N = 101), and concludes with a discussion of issues that must be addressed prior to incorporating prevention screening into HIV/AIDS case management.

Case management has been a difficult practice to track, particularly for the purposes of outcome measurements and accountability. As both policymakers and program administrators consider options for providing long-term care, the Data Analysis and Regulations Team of the California Department of Aging studied computerized client information for one of its case management programs to examine what we know about the people being served and the ability of the data collection system to meet the increasing demand for accountability. This article details the results of our study and discusses their implications within the dynamics of a changing social service environment.

The question has never been whether health care will change. Its evolution is continual, and predictions about its future often are about as accurate as 1930s science fiction. Even so, several trends already have emerged that some experts claim provide an interesting glimpse of what's to come--both in case management and in the industry at large.

Case managers are crucial to any well-designed disease management program. However, in the progressive course of serious illness, patients, their families, and MCOs need the skills of case manager more than ever to help them through end-of-life care choices. The author describes what case managers will need in their "toolbox" to provide insight to these health plan members.

Within the German statutory health care system the practice of sociomedicine as an applied health science is mainly related to individual aspects of theinsured persons. Combining factors due to medical and socio-economical developments it plays an important integrative role as so to say a lawyer of the patients. Furthermore, practical sociomedicine must provide consultant services to support the social insurance in the sphere of shaping the health care system. Profound knowledge on the required level must be acquired by graduate studies and can be deepened by well-planned continuing medical education. Professionalism in providing services and fulfillment of legal obligations can be achieved by standardisation of social medical procedures, scientific orientation towards public health aspects, appropriate methods of delivering medical knowledge, use of information systems, refinement of co-operation, quality management, social medical controlling, application of modern planning and control concepts as well as model leadership.

In 1989 David Moxley produced a text for generic case management in the human services. He has revisited his initial work and argues that the case management concept has taken on diverse meaning as it has been applied more widely and for very different agendas. It may have emerged in community care, but is now being utilised as a tool of restructuring in all arenas of service provision. Moxley now suggests five distinct scenarios for the future of case management: community support and the organisation of support systems for people with disabilities; management of the economic costs of human services; the management of undesirables; the management of clinical pathways; recipient management services. His commentary is based on his U.S. experience. This article will examine the relevance of his predictions to the Australian context.

News of the nation's shrinking health care labor force was made official with the publication of population data in a recent issue of the Journal of the American Medical Association. The report claimed that 40% of RNs will be over 50 before 2010. What does this mean for hospital case managers? Transition, according to industry experts. The role of the case manager will need better definition as shortages blur lines between patient care and traditional management.

Case management has been an effective treatment model for maintaining costs while preserving quality of care for vulnerable populations who are frequent care users. Nursing case management has been effective in improving health outcomes in chronically ill populations. Specifically, nurse practitioner care has been as effective, and in some areas, more effective in managing chronic health problems of patients than care provided by physicians. Cardiovascular disease is a chronic condition, often accompanied by long-term symptoms and disability, that is prevalent in the United States population. Outpatient nursing case management for chronic health problems associated with cardiovascular disease is posited as a model for a heavily used system that maintains quality of care in this group.

Objective: Meta-analytical methods were used to investigate the effectiveness of case management and to compare outcomes for assertive community treatment and clinical case management., Methods: Controlled studies of case management published between 1980 and 1998 were identified from reviews and through database searches. The results were quantitatively combined and compared with results of studies of mental health services without case management. Combined effect sizes and significance levels for 12 outcome domains were calculated. Analysis of homogeneity was used to explore differences between models., Results: Forty-four studies were analyzed; 35 compared assertive community treatment or clinical case management with usual treatment, and nine directly compared assertive community treatment with clinical case management. Both types of case management were more effective than usual treatment in three outcome domains: family burden, family satisfaction with services, and cost of care. The total number of admissions and the proportion of clients hospitalized were reduced in assertive community treatment programs and increased in clinical case management programs. In both programs the number of hospital days used was reduced, but assertive community treatment was significantly more effective. Although clients in clinical case management had more admissions than those in usual treatment, the admissions were shorter, which reduced the total number of hospital days. The two types of case management were equally effective in reducing symptoms, increasing clients' contacts with services, reducing dropout rates, improving social functioning, and increasing clients' satisfaction., Conclusions: Both types of case management led to small to moderate improvements in the effectiveness of mental health services. Assertive community treatment had some demonstrable advantages over clinical case management in reducing hospitalization.

We now reside in a data-driven health care environment and methods for gathering, presenting, and evaluating relevant data about health care systems are paramount. This article expands on the importance of evaluating the outcomes of case management and how collecting relevant clinical and cost data can provide an infrastructure on which to base future decisions. Data-based decision making in case management is crucial for ensuring quality of care and the appropriate management of patient outcomes, and it underpins the viability of this delivery model of care.

Family-centered care means, in the broadest sense, welcoming the family as partners in the care of the child. Family-centered care challenges us to create a new vision of a hospital environment that works in a very different way and that can actually improve clinical outcomes. This report describes one hospital's journey into family-centered care--its accomplishments and its challenges. It should be noted that, although this report describes family-centered care in a children's hospital, the philosophy beautifully adapts to an adult facility.

The purpose of the qualitative evaluation study discussed in this article was to examine the AIDS case management model under which five nonprofit AIDS service organizations (ASOs) in Midcity were operating. The study was organized around 40 qualitative interviews with executive directors, directors, and case managers. The finding was that AIDS case management is evolving to accommodate the changing environmental/contextual conditions that have resulted from combination drug therapies (protease inhibitors) introduced in 1996. The agencies are responding to the changes individually rather than as a network, and responses vary among the agencies. Institutional theory, an examination of the interconnectedness of clients, the ASOs, and their environmental context guided the analysis of the findings.

Managed care is the current state of health care delivery. How to respond to managed care's provider expectations is the key issue for all mental health care professionals. The adaptive response, based on managed care's definition of value and regardless of theoretic orientation, must be clear and definitive in terms of what the provider will do; why the provider will do it; how the provider will specifically achieve patient relief; and how the provider, patient, and managed care representative will know when that change has been achieved. In the managed care era, clinicians must satisfy patients, managed care representatives, and themselves by producing a valid and effective treatment product for all parties involved in the interplay of mental health care delivery.

A wide gap exists in the American health care system between what we know good geriatric mental health care services should look like and the types of services generally available. Cost effective treatment requires a continuum of care in which geriatric psychiatry and primary care geriatric services are integrated in an aggressively case managed model. MCOs have the infrastructure and tools at their disposal to make this work, but they must incorporate into their programs and approaches expert knowledge of the unique clinical problems of the frail elderly.

Eight published literature reviews of case management were evaluated to determine areas of consensus regarding outcomes associated with full service, broker, and hybrid models. Full service was recommended for "best practice" status and the effectiveness of the broker model was seriously questioned. Research evaluating para-professional and peer assisted models of case management, a potential method for improving outcomes, was also reviewed. One promising peer-assisted model was identified and described. Although the use of paraprofessionals and peers in case management holds promise, much more research is needed before the effectiveness of this approach can be confidently determined.

There is a public discussion in Politics and Health services whether managed care should be realized in Germany. The German Medical Services of the Statutory Health Insurance (MDK) are also involved and have great interest and an opinion about this topic because the introduction of managed care or elements of managed care will influence the cooperation between the MDK and the German Statutory Health Insurance. The following article informs on certain elements of managed care already practised in Germany and discusses which of these elements can be used more intensively in the future according to Social Laws and developed structures.