CASE MANAGEMENT : EVOLUTION OF THE CONCEPT IN THE 80 ’ S AND 90 ’ S

1 MNS; 2 PhD, Associate Professor, e-mail: tite@eerp.usp.br; 3 MNS, Doctoral student at Public Health; 4 Doctoral student for Fundamental Nursing Graduate Program; 5 PhD, Faculty; 6 Master student in Public Health at the Nursing School. University of São Paulo at Ribeirão Preto College of Nursing WHO Collaborating Center for Nursing Research Development, Brazil CASE MANAGEMENT: EVOLUTION OF THE CONCEPT IN THE 80’S AND 90’S

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.La gerencia de caso, terminología presente en casi todos los ambientes de cuidado de salud americano, utilizada para coordinar servicios comunitarios con resultados satisfactorios para el paciente en un determinado período de tiempo, con recursos limitados.A través del tiempo, fue utilizado con diferentes propósitos.El estudio tuvo como objetivo, mostrar la historicidad de la gerencia de caso, expresada por la literatura del área de enfermería americana, en las décadas de 80 y 90, de acuerdo con el uso, significado y aplicación, según el referencial de análisis de concepto.La recolección de datos, fue realizada en dos periódicos: "Nursing Management" y "Journal of Nursing Administration".Los resultados presentaron la gerencia de caso como el proceso que atiende a un objetivo común y donde la calidad y costo de la atención son elementos importantes e influyentes en el transcurso del tiempo y prioriza su práctica en poblaciones definidas como de alto risco y alto costo.DESCRIPTORES: gerencia de caso, gerencia de caso de enfermería, cuidado gerencial O gerenciamento de caso, terminologia presente em quase todas as situações de cuidado de saúde americano, utilizado para coordenar serviços comunitários com resultados satisfatórios para o paciente num determinado período de tempo, com recursos restritos.Ao longo do tempo, utilizou-se com diferentes propósitos.O estudo teve como objetivo mostrar a historicidade do gerenciamento de caso expresso pela literatura da área de enfermagem americana, nas décadas de 80 e 90, de acordo com o uso, significado e aplicação, segundo um referencial de análise de conceito.Realizou-se, a coleta de dados, em dois periódicos: "Nursing Management" e "Journal of Nursing Administration".Os resultados apresentaram o gerenciamento de caso como o processo que atende a um objetivo comum, sendo a qualidade e custo da assistência, os elementos presentes e influentes no decorrer do tempo, focalizando a sua prática em populações definidas como de alto risco e alto custo para os serviços de saúde.

INTRODUCTION
Case Management is a relatively recent terminology in the American health care environment.It appeared as a response to the high cost that originated from changes in legislation and technologies, the modern mechanisms of health care, and the new social tendencies (1) .
In Brazil, this modality of service is presented as a sub-component of clinical management, in the proposals of Integrated Health Systems.It is defined as a collaborative effort which diagnoses, plans, implements, coordinates, supervises and evaluates different options of care according to the health needs of a person through the available resources and communication to promote quality and cost effective results (2) .It is performed by a case manager, in general a nurse, social worker or a small health team, which is organized according to the particular institution.Its essential function is patient advocacy, and its main work tool is communication.
This modality points to strategies to improve patient care considering more flexible, innovative and human factors.Nurses are seen as the most appropriate professionals for the practice of this care modality, due to their clinical knowledge, ability to offer holistic care, advocate for the patient, and due to their relatively deeper knowledge of the care provided by the other health care professionals (3) .
Therefore, using case management, it is possible to optimize self-care, reduce fragmentation of care, improve the quality of life of the patient, reduce length of stay, improve satisfaction of the patient and the professionals involved with the process, and promote the cost effective use of the scarcest resources.
In this sense, the study of this theme is justified considering its adequate application to the reality of nursing practice and to Brazilian health services, in an attempt to respond to the emergent needs in care delivery.
In this regard, it is considered imperative recognize the historical evolution of this modality of health care delivery, with the aim of identification of its basic characterizing elements.

OBJECTIVE
Describe the historical evolution of the "case management" concept, as expressed in the American nursing literature in the 1980's and 1990's.

METHODOLOGY
Concept analysis was used as a research method.It consists of a methodological option available in the literature with a large number of structures to guide the process.The choice of an adequate analysis strategy depends upon the development of knowledge within a certain concentration area (4) .
There are three stages to develop concepts in a specific area: "concept analysis", "concept synthesis", and "concept derivation".The choice for any one of them depends upon the context in which the researcher is working, and they are all useful in the development and construction of a theory.Both concept "synthesis" and "derivation", depend upon the "analysis" (5)   .
In order to obtain a concept definition, it is necessary to go through "concept analysis", understood as a centralization of knowledge development, and seen as a way to contribute to nursing to evolve as a science in the realm of professional practice (6) .
The clearer the concepts, i.e. the expression of this essential characteristic, the better will be the understanding among those who utilize them, upon understanding these characteristics that appear frequently, when a concept is described (5)   .
A new model of "concept analysis" with its basis in the inductive and descriptive method, giving emphasis on evolutionary nature of the concept (6) .The author understands concept as an intellectual and abstract representation of reality, i.e., the concept is "formed by the identification of characteristics common to a class of objects or phenomena and the abstraction and clustering of these characteristics along with some means of expression".Its aim is to clarify the use of concept in a specific context and period of time, providing a consistent basis for the interpretation of results, revealing the heuristic values of "concept analysis".This method is expressed by eight primary activities and many of these are carried out simultaneously along the investigation.The main point is to clarify the intention and dimension of "concept analysis", establishing relations between the tasks: -Identify the concept of interest and associated expressions or terms.
-Identify and select an appropriate universe for data collection.
-Collect data recognizing the attributes of the concepts, and also the substitute terms, related antecedents and consequences.
-Identify concepts related to the concept of interest.
-Analyze data regarding the characteristics of the concept.
-Identify a model case of the concept, if appropriate.
-Identify hypotheses and implications for other studies.
The process of concept development can be presented as a evolutionary cycle that continues through time and within a particular context, referred as a particular discipline, cultural group or sometimes, provided by a theoretical framework (6)   .This evolutionary cycle is integrated by three distinct influences in the development of concept, named as "significance", "use", and "application" of the concept.
The concept acquires "significance" through its use in each situation, and it is influenced by internal and external factors that amplify and refine it.
The "use" of concept expresses the common manner of employing it and the situations appropriate to its application.Includes means of expressions and carries with it "concept attributes", which are relevant for language in its many diverse natures.
The "application" reveals itself when a concept takes on a particular "use", and the understanding of this is diffused in social interactions.It reflects the concept that has been made effective and identified in some context, and is continuously reevaluated and refined.The "application" reveals not only the strengths of the concept, but also its limitations.
Certain aspects of the concept gain significance because of needs that appear with time stimulating new explorations of "use" and "application" in continuous evaluation.
This method of analysis was used in this study in the construction of the historical evolution of case management according to its significance, use and application with the ambitious goal of contributing to a better understanding of this modality of nursing care delivery.
In this sense, this study was conducted through some of the phases or tasks (6) , such as: identification of the concept of interest and associated expressions; identification and selection of the appropriate field for data collection; data collection and data analysis with identification of the characteristics of the concept.

Choosing the field of study and data collection
We have performed a literature-based analysis and the decisions related to the sample were based on the purpose of the study.Steps were taken towards the identification of nurse authors who, in the American literature, have published about case management so we could obtain the vision and understanding of the subject within the health area, through the point of view of nursing.
Through the exhaustive reading of the bibliographical material, it was possible to get a closer look of the theme under study; case management was then identified as a new terminology to the Brazilian health system, and as a concept that was completely developed in the American nursing field.
The field of data collection was the Main Library of the University of Sao Paulo at Ribeirão Preto.Two indexed nursing periodicals were chosen, namely Nursing Management and Journal of Nursing Administration, due to their emphasis in management and nursing care administration issues.
The literature review included articles published in the decades of 1980's or 1990's, indexed under the keywords: case management, case-managed care, nurse case management, nurse case manager, case manager.In order to enhance the credibility we adopted a complementary procedure while choosing the articles.Besides considering keywords and title, we investigate the ones that had an explicit definition of the concept of case management in the article.
Initially, a total of 53 articles were retrieved.The selection of those publications that met the established criteria for our investigation, "concept analysis" of case management, revealed the total of 39 articles.
Emphasize that in order to increase the credibility of the study, the selection of articles which will compose a sample for research needs to contain at least 30 % of the total number of documents that meet the preestablished criteria for the study (7) .In this sense, the total number of articles selected for this study is within the credibility zone referred by the author, since we have used a total of 74% of the 53 articles mentioned above.
Many exploratory readings of the publication were done identifying phrases, themes, words terms, expressions, and, when possible, full paragraphs, recording them on a separate document, to better organize the "concept analysis".Then, using these findings as a starting point, we have tried to pinpoint the description of the authors with regards to the concept.Therefore, after presenting the words and/or expressions that better represent the ideas of the authors, we have followed up on the orientation in order to specify the significance, use and application of case management in the studied period (6) .

Case Management: the construction of the concept over time
This construction has the goal of showing the historical evolution of case management over time, according to the use, significance and application of the concept (6) .
The literature expresses the concept of case management as a model of care delivery, where its essential attributes are the basis for quality and cost of care.They are elements that are present and influential over time.
The use of case management is justified through the feasibility of integrating and improving the cost and quality of care -a fundamental purpose of this modality (8)(9) .Another important function is to restructure the functions within a health team.It starts with a multidisciplinary team, which translates itself as a collaborative model of interdisciplinary care, which aims at humanizing health care (10-11)   .It transcends specialties where all members of the team participate and collaborate in the achievement of the common goals (12) .It also prevents the unnecessary care activities, reducing duplication and fragmentation.Nurses are adopting case management in hospital and community environments in an attempt to reduce compartmentalization of care and improve its quality (13) .
Through the process of case management, the specific and relevant needs of patients are identified, and are considered as priority goals that have to be attained and managed through the continuum of care.
It focuses its practice in high risk and high cost populations, since they represent the largest portion of health expenditure in the developed countries, given the complexity of the diseases and need of advanced technologies for diagnosis what increases the resources necessary in care delivery, and also the length of stay in hospitals.
The case management works as a viable strategy for the coordination and delivery of health care for highrisk populations (14) .The patients with AIDS, spinal cord injury, liver transplants, hemodialysis, chronic diseases and premature babies in neonatal intensive care units, are among others, considered as high risk and high cost populations (15) .
In this sense, the practice of case management is economically important for cost contention in health care services, through the appropriate use of resources.
With regards to the significance or meaning of case management through time, it is refered to as a system, method, structure, process, strategy and model of care.It is understood as the path or process by which a common goal is attained, emphasizing avoidable mistakes in view of a well-defined result, which defines it as a method.
As a system, it is conceived as an organized structure that is built from the most fundamental and essential aspects of care, through the setting up of the elements or parts of a whole, in the health team.
In nursing, it has been developed and implemented a great number of models of case management (16) .In general, they fit into one of three different patterns.
In pattern number one, the nurse case manager In pattern number two, the nurse case manager plans, coordinates or delivers care and evaluates care, in general for specialized and high-risk groups.However, clinical protocols, maps of care, and managed care activities generally are not present.The case manager is limited to a single environment, such as the hospital or the community.Models like these, which aim mostly at improving quality of care, instead of cost reduction, are said to be of second generation (16) .
In pattern number three, case management occurs through the continuum of care and time.Case management promotes continuity of care from hospitalization through outpatients' clinics and from there to the internal (domestic) environment.It attains certain goals of improvement in patient satisfaction (17) .
The total management of care can also assure a wide scope of health services.The patient will have the opportunity of using the services or resources according to his/her needs, which would in fact be very hard to implement in the absence of a case manager, who identifies, coordinates and negotiates services and resources.
With regards to the application of case management, in the analysis of the concept through time (year) it is present mostly in the hospital environment, although it's beginning occurred in the external environment (insurance companies, independent and private practices, among others).
This fact is attributed to the economical changes that resulted in modifications in the reimbursement of the cost of care, which presented to hospitals the challenge of delivering quality care in a cost efficient manner, and in a context of limited resources.In this context, the hospitals have looked for models or strategies that allowed to meet the great challenge of the new system of health, which resulted in the adoption of case management.By using this methodology, they have attained good results in terms of cost and quality.This fact can be considered as the great motivation for the application of case management in the hospitals.
In the following Figure 1 it is shown the evolution of the concept of case management in the 80's and 90's.

FINAL CONSIDERATIONS
Through the method of "concept analysis" (6)   , it was possible to identify the main characteristics of the concept of case management through the use, significance and application of the concept.This concept is referred as a modern terminology in the American health service delivery, where its main purpose is to integrate quality and cost through total care management.It permits the supervision and evaluation of patient care, assuring a wide scope of the services according to his/her needs with appropriate use of the resources.Its starting point is an interdisciplinary team, which translates into a collaborative model, and interdisciplinary care, which aims at turning care into a more human affair.It transcends specialties in such a way that all the members of the team participate and collaborate in the achievement of a common goal; where the specific and relevant needs of the patient are considered as priorities.
Moreover, case management focuses its practice in high risk and high cost populations, that represent the greatest part of expenses with health in developed countries.
Being that, it is important to bring the discussion about case management to the Brazilian care environment as an attempt to enable the practice of some elements that characterize it, and therefore, to contribute towards the improvement of quality and continuity of care in an efficient and appropriate way, through an interdisciplinary practice.Hopefully, it would bring a response not only to the emergent needs of the Brazilian health system, but also to Brazilian Nurses, since they will be the main actors in the application of this modality of care delivery.
uses the clinical protocols, maps of care or other plans of multidisciplinary care to plan, coordinate, and evaluate the care of groups of high risk patients, in a variety of hospital environments, through the whole continuum of care.Activities of managed care, such as: utilization review, financial auditing, retrospective and present quality auditing, and documentation of the variables are important components.These are considered first generation modules, which mainly aim at cost reduction.

Figure 1 -
Figure 1 -Representation of the concept of case management in time (year) according to use, significance and apllication