RESEARCH STARTER

Case management

Case management is a coordinated process that addresses the health and human services needs of individuals with chronic or catastrophic illnesses. The primary goal is to optimize outcomes for patients, families, healthcare providers, and payers, such as insurance companies. A case manager, often a nurse or healthcare professional, acts as a crucial point of contact, advocating for patients and guiding them through the complexities of the healthcare system. This involves assessing patient needs, coordinating care among multiple providers, and facilitating access to necessary resources like medical equipment and transportation.

Historically, case management emerged from organized nursing efforts in the 19th century, recognizing the importance of hygiene, nutrition, and adequate care access for vulnerable populations. Over the decades, legislative initiatives, including the Social Security Act and the Affordable Care Act, have underscored the significance of case management, particularly as healthcare costs rise. By streamlining processes and minimizing duplication of services, case management not only benefits patients in achieving maximum health but also aids healthcare payers in ensuring efficient use of resources. As the population ages and chronic illnesses become more prevalent, case management is increasingly essential for navigating healthcare effectively.

Full Article

Case management is a process in which the health and human services needs of a chronically or catastrophically ill patient are coordinated to ensure the best possible outcome for the patient and family, the healthcare providers, and the payers, such as health insurance companies. It involves determining what the patient needs to reach a maximum level of health and function, and how best to meet those needs with the available resources. The case manager, usually a nurse or other medical professional, will serve as a point of contact between all the partners in the situation, serving as an advocate and guide for the patient in navigating the healthcare system. This will usually include communicating with providers and payers; researching and arranging for assistance such as mobility aids, home medical equipment, and transportation; and coordinating care among multiple providers. Case management has become important as healthcare costs have continued to rise.

Background

Case management had its origins in the nineteenth century with the rise of organized nursing programs. Trained nurses realized the importance of hygiene, nutrition, adequate clothing, and shelter to maintaining health. They were also often aware of options for healthcare, such as clinics, where a sick or injured person could receive medical assistance. They began promoting these services to the sick people they tended and advocating for more such services.

In many cases, these efforts began with the most vulnerable, such as infants and children, disabled individuals, and older adults. The nurses’ goal was to provide the best possible outcome for the patient, whether that was a healthy childhood, an improved ability to get around, or a dignified and pain-free death. Florence Nightingale and the nurses trained through her schools were pioneers in this, as was American nurse Lillian Wald.

Wald, a nurse trained at the New York Hospital, became aware that many immigrants in Manhattan lacked access to medical care, including pre- and postnatal care when they had babies. In 1893, she founded the Visiting Nurse Service of New York, which in the early twenty-first century is the largest nonprofit home and community-based health care agency in the United States (U.S.). This program helped spark interest in organizing and coordinating healthcare services for the poor and underserved populations, especially in large urban areas. These efforts led to the formation in the early 1900s of the US Public Health Service (PHS), which focused on the sanitation and immunization needs of a population that was increasingly concentrated because of the nation’s industrialization. While the PHS traces its roots to the Marine Hospital Service (1798), it was officially renamed the Public Health and Marine-Hospital Service in 1902 and finally the U.S. Public Health Service in 1912.

By 1905, hospitals, such as Massachusetts General, were beginning to hire social workers to help patients get care without duplicating services. In 1929, the Baylor Plan laid the groundwork for the first Blue Cross health plan in Texas; this led to additional interest in case management, as health insurers attempted to get the best results possible for the money being spent. The federal government approved the Social Security Act in 1935; this was a major expansion of the national government’s role in helping individuals have access to the health care and social services they needed. Efforts to coordinate care for veterans returning from World War II in the 1940s also increased awareness about and efforts in case management.

The 1960s and 1970s saw increased efforts to provide and coordinate care for the disabled, including the passage of the Medicare and Medicaid programs, which became law in 1965. The importance of case management grew as government agencies and insurers tried to ensure patients were getting the best possible care for the money being allocated. These legislative efforts and others, including the Americans with Disabilities Act (1990), the Family and Medical Leave Act (1993), the Health Insurance Portability and Accountability Act (1996), and the Patient Protection and Affordable Care Act (2010), all increased the importance of case management as a way to make sure the patient got all the care needed to improve and maintain the optimal level of health.

Overview

Nurses realized that both the mother and infant would struggle if the mother did not understand the need to maintain a clean environment, or lacked enough food to nourish herself adequately for breastfeeding. Patients with injuries or chronic illnesses faced similar issues; lack of sanitation could cause infections that complicated care, while nourishing food was necessary for recovery and ongoing health. Some patients faced other challenges, such as affording medicines or mobility aids such as wheelchairs, or needed transportation to get to medical appointments. In some cases, patients with limited or no incomes required assistance identifying and signing up for services that could help them access healthcare.

Case management services help patients with all these needs, aiding them in finding and accessing the care they need to become as healthy as possible. The goal is to help the patient reach full health, or the highest level of self-management possible. The case manager’s knowledge of medicine combined with an understanding of the available services and products can help the patient achieve this goal.

At the same time, case management benefits those who pay for medical services, such as government agencies or health insurers, because it maximizes the results they get for the money spent on the patients’ care. Through case management, payers can help eliminate wasteful spending on duplication of services. For instance, if a patient is seen by one physician and then needs to see a second specialist, a case manager can help ensure that the necessary records, x-rays, and test results are forwarded from one doctor to the other. This can help minimize the money spent on testing, as well as care delays waiting for records or new test results. It also helps reduce the workload of physicians and other healthcare providers, freeing up resources for other patients. In 2024, CMS finalized new interoperability and prior-authorization rules aimed at improving electronic information-sharing and reducing delays and duplication in patient care.

Rising healthcare costs make case management more appealing to providers and payers. Healthcare providers are seeing an increasing number of people living with chronic illnesses, veterans with life-altering injuries, and an increased population of older adults. Further, the ability of medical science to save and maintain the lives of premature infants, cancer patients, and others who would not have survived in the past adds to the number of people who need help navigating the world of healthcare to maintain and restore their well-being. Beginning in 2024, Medicare started covering principal illness navigation services for some patients with serious conditions, reflecting growing policy support for care navigation and coordination.

Case managers generally complete an applicable college-level program in nursing, social work, or a similar field. They often pursue licensing and certification to have the widest range of opportunities. Employment options for case management can be found with government agencies, health insurers, and healthcare facilities. Case management has seen a significant shift in the remote and hybrid work environments as more hospitals see the need for great flexibility, resource optimization, and access to a larger pool of qualified candidates. The 2025 update to the Certified Case Manager exam blueprint ensures the credential remains aligned with the latest industry standards identified in the 2024 job-task analysis.


Bibliography

“About VNS Health.” Visiting Nurse Services of New York, www.vnsny.org/who-we-are/about-us/. Accessed 26 Mar. 2025.

Aliotta, Sherry. “Case Management Standards of Practice: A Road Map to Excellence.” Case Management Society of America, 24 Jan. 2023, cmsatoday.com/2023/01/24/case-management-standards-of-practice-a-road-map-to-excellence/. Accessed 31 Mar. 2026.

Amado, Angela Novak, et al. “Research Review of Effectiveness of Case Management in the United States.” Case Management: Historical, Current, and Future. Brookline, 1989, pp. 1–20, mn.gov/mnddc/learning/document/GT062.PDF. Accessed 31 Mar. 2026.

Blue Cross Blue Shield Association. “History of Health Care.” History of Health Care. Accessed 31 Mar. 2026.

“Case Management: Mental Health, Transition Linkage And Aftercare.” Illinois Department of Human Services, www.dhs.state.il.us/page.aspx?item=30472. Accessed 31 Mar. 2026.

Centers for Disease Control and Prevention. “The Roots of Public Health and CDC.” David J. Sencer CDC Museum, 24 Mar. 2021, The Roots of Public Health and CDC. Accessed 31 Mar. 2026.

Centers for Medicare & Medicaid Services. “CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).” CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), 17 Jan. 2024. Accessed 31 Mar. 2026.

Centers for Medicare & Medicaid Services. “Principal Illness Navigation Services.” Medicare.gov, Principal Illness Navigation Services. Accessed 31 Mar. 2026.

Commission for Case Manager Certification. “CCMC Announces Updated CCM® Exam Blueprint Effective August 2025.” CCMC Announces Updated CCM® Exam Blueprint Effective August 2025, 4 Dec. 2024. Accessed 31 Mar. 2026.

Ferguson, Tiffany. “The History of Social Work in the Hospital Setting.” CMSA Today, 4 Mar. 2024, The History of Social Work in the Hospital Setting. Accessed 31 Mar. 2026.

“5 Skills Every Case Manager Should Master.” AMN Healthcare, 19 Aug. 2024, www.amnhealthcare.com/blog/revenue-cycle/5-essential-skills-every-case-manager-should-master/. Accessed 31 Mar. 2026.

Kurland, MaryBeth. “Case Management Profession: Trends & Foresight.” Commission for Case Manager Certification, 5 Apr. 2023, ccmcertification.org/blog/case-management-profession-trends-foresight. Accessed 31 Mar. 2026.

Mullahy, Catherine M., and Jeanne Boling. “Case Management—The Origins, Evolution and Future.” Mullahy and Associates, www.mullahyassociates.com/wp-content/uploads/2016/04/origins-evolution-and-future.pdf. Accessed 31 Mar. 2026.

“What Is a Case Manager?” Case Management Society of America, 2021, cmsa.org/who-we-are/what-is-a-case-manager/. Accessed 31 Mar. 2026.

Full Article

Case management is a process in which the health and human services needs of a chronically or catastrophically ill patient are coordinated to ensure the best possible outcome for the patient and family, the healthcare providers, and the payers, such as health insurance companies. It involves determining what the patient needs to reach a maximum level of health and function, and how best to meet those needs with the available resources. The case manager, usually a nurse or other medical professional, will serve as a point of contact between all the partners in the situation, serving as an advocate and guide for the patient in navigating the healthcare system. This will usually include communicating with providers and payers; researching and arranging for assistance such as mobility aids, home medical equipment, and transportation; and coordinating care among multiple providers. Case management has become important as healthcare costs have continued to rise.

Background

Case management had its origins in the nineteenth century with the rise of organized nursing programs. Trained nurses realized the importance of hygiene, nutrition, adequate clothing, and shelter to maintaining health. They were also often aware of options for healthcare, such as clinics, where a sick or injured person could receive medical assistance. They began promoting these services to the sick people they tended and advocating for more such services.

In many cases, these efforts began with the most vulnerable, such as infants and children, disabled individuals, and older adults. The nurses’ goal was to provide the best possible outcome for the patient, whether that was a healthy childhood, an improved ability to get around, or a dignified and pain-free death. Florence Nightingale and the nurses trained through her schools were pioneers in this, as was American nurse Lillian Wald.

Wald, a nurse trained at the New York Hospital, became aware that many immigrants in Manhattan lacked access to medical care, including pre- and postnatal care when they had babies. In 1893, she founded the Visiting Nurse Service of New York, which in the early twenty-first century is the largest nonprofit home and community-based health care agency in the United States (U.S.). This program helped spark interest in organizing and coordinating healthcare services for the poor and underserved populations, especially in large urban areas. These efforts led to the formation in the early 1900s of the US Public Health Service (PHS), which focused on the sanitation and immunization needs of a population that was increasingly concentrated because of the nation’s industrialization. While the PHS traces its roots to the Marine Hospital Service (1798), it was officially renamed the Public Health and Marine-Hospital Service in 1902 and finally the U.S. Public Health Service in 1912.

By 1905, hospitals, such as Massachusetts General, were beginning to hire social workers to help patients get care without duplicating services. In 1929, the Baylor Plan laid the groundwork for the first Blue Cross health plan in Texas; this led to additional interest in case management, as health insurers attempted to get the best results possible for the money being spent. The federal government approved the Social Security Act in 1935; this was a major expansion of the national government’s role in helping individuals have access to the health care and social services they needed. Efforts to coordinate care for veterans returning from World War II in the 1940s also increased awareness about and efforts in case management.

The 1960s and 1970s saw increased efforts to provide and coordinate care for the disabled, including the passage of the Medicare and Medicaid programs, which became law in 1965. The importance of case management grew as government agencies and insurers tried to ensure patients were getting the best possible care for the money being allocated. These legislative efforts and others, including the Americans with Disabilities Act (1990), the Family and Medical Leave Act (1993), the Health Insurance Portability and Accountability Act (1996), and the Patient Protection and Affordable Care Act (2010), all increased the importance of case management as a way to make sure the patient got all the care needed to improve and maintain the optimal level of health.

Overview

Nurses realized that both the mother and infant would struggle if the mother did not understand the need to maintain a clean environment, or lacked enough food to nourish herself adequately for breastfeeding. Patients with injuries or chronic illnesses faced similar issues; lack of sanitation could cause infections that complicated care, while nourishing food was necessary for recovery and ongoing health. Some patients faced other challenges, such as affording medicines or mobility aids such as wheelchairs, or needed transportation to get to medical appointments. In some cases, patients with limited or no incomes required assistance identifying and signing up for services that could help them access healthcare.

Case management services help patients with all these needs, aiding them in finding and accessing the care they need to become as healthy as possible. The goal is to help the patient reach full health, or the highest level of self-management possible. The case manager’s knowledge of medicine combined with an understanding of the available services and products can help the patient achieve this goal.

At the same time, case management benefits those who pay for medical services, such as government agencies or health insurers, because it maximizes the results they get for the money spent on the patients’ care. Through case management, payers can help eliminate wasteful spending on duplication of services. For instance, if a patient is seen by one physician and then needs to see a second specialist, a case manager can help ensure that the necessary records, x-rays, and test results are forwarded from one doctor to the other. This can help minimize the money spent on testing, as well as care delays waiting for records or new test results. It also helps reduce the workload of physicians and other healthcare providers, freeing up resources for other patients. In 2024, CMS finalized new interoperability and prior-authorization rules aimed at improving electronic information-sharing and reducing delays and duplication in patient care.

Rising healthcare costs make case management more appealing to providers and payers. Healthcare providers are seeing an increasing number of people living with chronic illnesses, veterans with life-altering injuries, and an increased population of older adults. Further, the ability of medical science to save and maintain the lives of premature infants, cancer patients, and others who would not have survived in the past adds to the number of people who need help navigating the world of healthcare to maintain and restore their well-being. Beginning in 2024, Medicare started covering principal illness navigation services for some patients with serious conditions, reflecting growing policy support for care navigation and coordination.

Case managers generally complete an applicable college-level program in nursing, social work, or a similar field. They often pursue licensing and certification to have the widest range of opportunities. Employment options for case management can be found with government agencies, health insurers, and healthcare facilities. Case management has seen a significant shift in the remote and hybrid work environments as more hospitals see the need for great flexibility, resource optimization, and access to a larger pool of qualified candidates. The 2025 update to the Certified Case Manager exam blueprint ensures the credential remains aligned with the latest industry standards identified in the 2024 job-task analysis.


Bibliography

“About VNS Health.” Visiting Nurse Services of New York, www.vnsny.org/who-we-are/about-us/. Accessed 26 Mar. 2025.

Aliotta, Sherry. “Case Management Standards of Practice: A Road Map to Excellence.” Case Management Society of America, 24 Jan. 2023, cmsatoday.com/2023/01/24/case-management-standards-of-practice-a-road-map-to-excellence/. Accessed 31 Mar. 2026.

Amado, Angela Novak, et al. “Research Review of Effectiveness of Case Management in the United States.” Case Management: Historical, Current, and Future. Brookline, 1989, pp. 1–20, mn.gov/mnddc/learning/document/GT062.PDF. Accessed 31 Mar. 2026.

Blue Cross Blue Shield Association. “History of Health Care.” History of Health Care. Accessed 31 Mar. 2026.

“Case Management: Mental Health, Transition Linkage And Aftercare.” Illinois Department of Human Services, www.dhs.state.il.us/page.aspx?item=30472. Accessed 31 Mar. 2026.

Centers for Disease Control and Prevention. “The Roots of Public Health and CDC.” David J. Sencer CDC Museum, 24 Mar. 2021, The Roots of Public Health and CDC. Accessed 31 Mar. 2026.

Centers for Medicare & Medicaid Services. “CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F).” CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), 17 Jan. 2024. Accessed 31 Mar. 2026.

Centers for Medicare & Medicaid Services. “Principal Illness Navigation Services.” Medicare.gov, Principal Illness Navigation Services. Accessed 31 Mar. 2026.

Commission for Case Manager Certification. “CCMC Announces Updated CCM® Exam Blueprint Effective August 2025.” CCMC Announces Updated CCM® Exam Blueprint Effective August 2025, 4 Dec. 2024. Accessed 31 Mar. 2026.

Ferguson, Tiffany. “The History of Social Work in the Hospital Setting.” CMSA Today, 4 Mar. 2024, The History of Social Work in the Hospital Setting. Accessed 31 Mar. 2026.

“5 Skills Every Case Manager Should Master.” AMN Healthcare, 19 Aug. 2024, www.amnhealthcare.com/blog/revenue-cycle/5-essential-skills-every-case-manager-should-master/. Accessed 31 Mar. 2026.

Kurland, MaryBeth. “Case Management Profession: Trends & Foresight.” Commission for Case Manager Certification, 5 Apr. 2023, ccmcertification.org/blog/case-management-profession-trends-foresight. Accessed 31 Mar. 2026.

Mullahy, Catherine M., and Jeanne Boling. “Case Management—The Origins, Evolution and Future.” Mullahy and Associates, www.mullahyassociates.com/wp-content/uploads/2016/04/origins-evolution-and-future.pdf. Accessed 31 Mar. 2026.

“What Is a Case Manager?” Case Management Society of America, 2021, cmsa.org/who-we-are/what-is-a-case-manager/. Accessed 31 Mar. 2026.

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