Case management: high-intensity care for frail patients with complex needs

Case management has evolved beyond the functions of discharge planning and utilization review to a role of managing the delivery of services for populations across settings. The two forces driving this change are the growth of Medicare managed care and the increasing numbers of frail older patients with chronic disease. Necessary components of case management include a system of risk identification; an ability to link information, physicians and other providers; an interdisciplinary team approach; and the ability to follow identified older patients over time. In high intensity/low volume models, each case manager works directly with a small number of patients for a given episode of care or over time.