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Nurse Educator
Issue: Volume 24(5), September/October 1999, pp 5257
Copyright: 1999 Lippincott Williams & Wilkins, Inc.
Publication Type: [Article]
ISSN: 03633624
Accession: 0000622319990900000019
[Article]

Active Learning Strategies to Teach Case Management

Dickerson, Suzanne Steffan DNS, RN; Peters, Donna MS, RN; Walkowiak, Jennifer A. MS, RN; Brewer, Carol PhD, RN

Author Information
Suzanne Steffan Dickerson, DNS, RN, Clinical Associate Professor of Nursing, email: sdickers@acsu.buffalo.edu, State University of New York at Buffalo,
Donna Peters, MS, RN, Clinical Manager, for Home Care, Concord Visiting Nurses, Maine
Jennifer A. Walkowiak, MS, RN, System Director Case Management, Kenmore Mercy Hospital, Mercy Hospital, Organizations of Mercy Health System of Western New
York,
Carol Brewer, PhD, RN, Assistant Professor of Nursing, State University of New York at Buffalo.
To discuss this article, go to Nurse Educator's Forum http://www.nursingcenter.com Select these icons: People & Places, Forums, and Academic Education

Abstract
Changes in healthcare delivery require a new understanding of the concepts of case management in managed
care. The authors describe the construction and evaluation of a learning module that encourages active
engagement and skill development. Students develop an understanding of how to plan for care of populations in
an effort to meet managed care demands. This approach to teaching case management can be effective in an
educational setting and possibly in clinical settings as well.

Managed care is a strategy to reduce healthcare costs by controlling the use of services and improving quality
outcomes. This strategy includes a major shift in healthcare delivery from a service that is illnessoriented,
episodic, and settingbased to a service that is populationfocused and systembased and is oriented toward health
promotion and prevention. Such changes require a rethinking of the meaning of "healthcare." To prepare nurses to
practice, we as educators must have a clear understanding of this new environment. We need to focus on the
entire spectrum of health services and enhance our students' ability to assess patients, implement a health plan,
and take on responsibility for the resulting outcomes.

Case management, which has emerged from managed care, is a strategy that can have a positive and tangible
impact on bureaucratic barriers and can help in the shift to population management. Case management is defined
as:

a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and
services to meet individual health needs along the continuum of care through communication and available
resources to promote quality costeffective outcomes.1(p39)

Case management controls costs and use of resources by managing the care of highcost patients in certain
diagnostic groups. Case management is used in a variety of settings and is well suited to nurses because of their
skills in communication, patient advocacy, and coordination of care.

Conventional nursing educational practices reflect professionally defined acute care, needbased care models
that do not focus on costeffective care. The American Association of Colleges of Nursing's 2 vision for future
baccalaureate graduates includes newer roles involving primary and preventive care, health promotion, and care
of populations. Nurses must develop skills in case management, applied across settings; these require
interdisciplinary collaboration and optimal use of resources. As health care educators or staff educators, we must
prepare strategies to assist future practitioners to function in a managed care environment, to improve quality
care, and to help shape future practice.

To ensure appropriate preparation of students, we formed a partnership between nursing education and
nursing practice, as encouraged by AACN.2 In this collaborative effort, faculty members, an expert in case
management, and a local hospital system director set out to prepare and evaluate a learning module designed to
introduce managed care concepts and the process of case management and to engage the students in applying
these concepts in a written project.

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Active Learning Strategies

In the early 1980s, educational leaders began to focus their interest on describing methods to increase
teaching effectiveness. At that time, most teaching was in lecture format, and faculty were encouraged to
"actively involve and engage students in the process of learning."3(p2) Active teaching strategies "involve students
doing things and thinking about things they are doing."3(p2) Students must be engaged in tasks such as analysis,
synthesis, and evaluation, which require a higher order of thinking. Faculty can accomplish this by increasing the
students' involvement with the subject matter by developing skills in analysis and evaluation and urging students
to explore attitudes and values. Nursing faculty, in socializing students to the nursing profession, must encourage
students to develop their skills in thinking and application of knowledge in practice.

Bonwell and Eison 3 delineated several strategies for engaging students in active learning: enhancing lectures
by pausing for structured activities, effective use of questioning, cooperative learning groups, debates, role
playing, and simulations. These techniques involve planning and preparation as well as devising strategies to
simulate practice situations. This learning module uses the active learning strategies of modified lectures in the
classroom/seminar portion, with pauses for discussion to enhance comprehension and cooperative learning tasks in
small groups. The case management project is a problembased approach that simulates the development of a
populationbased plan for costeffective care across the continuum.

Seminar on Case Management

The format for the 4hour RNBS management class was that of an open seminar. The students were chosen
because they were initially trained in the traditional nursing model and would benefit from understanding the
changing healthcare system and case management concepts. The intent of the seminar is to develop a beginning
knowledge base in managed care, case management, and clinical pathways, as well as to acquire skills in
designing, implementing, and evaluating the pathway process. The class session is divided into halves, one
devoted to managed care concepts and case management in a historical context and the second concentrating on
the process of developing a tool for case management, the clinical pathway.

The learning objectives for the seminar are as follows:

1. Describe the basic concepts of managed care, case management, and clinical pathways. Rationale: To gain
understanding of the change in thinking from traditional individual needbased models to populationbased
models.
2. Discuss the benefits and weaknesses of managed care, case management, and clinical pathways. Rationale: To
gain understanding of the importance of the nursing role as case manager in maintaining highquality, cost
effective care.
The first half of the class on managed care provides an orientation to the changing paradigms of the
healthcare system, from a needbased, feeforservice model to a managed care, costdriven service model. Active
discussion of implications is encouraged by requesting students to give examples of changing patterns from their
own clinical experiences. The second part of the class includes a discussion of clinical pathways, a major tool used
to standardize care; pathways serve to monitor care, improve quality, and assist in effective resource utilization.
Smallgroup work provides a context for the students to assimilate how a pathway is conceptualized and to learn
by doing. A video on hospitalbased case management (Managed Care in the Acute Setting4) provides an example of
how pathway concepts might be implemented in a hospital setting.

We delineate several concepts integral to the understanding of managed care and case management (Table
1). These concepts were extracted from current literature and confirmed by case managers in practice. These
concepts are introduced in the seminar and are expanded on in the readings; they are central to understanding
managed care.

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Table 1. Concepts Central to Managed Care and Case Management

Written Project
The written assignment is designed to integrate all aspects of case management, from health promotion to
acute illness care through health restoration and maintenance. This holistic view of health includes planning for
each level of care. Table 2 includes a description of the assignment, along with related concepts.

Table 2. Case Management Plan

The student learning objectives for the paper are as follows:

1. Apply case management principles in a structured assignment. Rationale: Active application of concepts to a
populationbased example engages students in synthesis of information and application of concepts in practice.
2. Apply concepts of quality outcome management by defining outcome criteria and constructing a variance
monitoring plan. Rationale: Students engage in an evaluation process that is applicable to a practice setting.
This assignment is an active learning strategy that encourages active engagement and skill development.
Skills include identifying a population at risk, identifying goals and strategies to promote health and prevent
illness in this group, and planning implementation. Students are asked to think as if they are providers planning
for care of a population at risk.

In addition to the final written paper, the students actively participate in developing a plan. For this exercise,
the students use standards or benchmarks in the literature as the basis for developing diseasespecific clinical

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pathways. Students also investigate potential resources and contact payers to obtain cost data on the various
components of the plan. The assignment is designed so the students could work in their area of expertise or
current practice. Students are also allowed to work on the assignment in groups of two; this encourages
collaboration and sharing of knowledge and contacts.

A general reading assignment and a bibliography of current articles on case management are distributed as a
basic reference. Students use library resources and contact local healthcare agencies, community resources, and
insurance providers to obtain cost and length of stay data as needed to complete the paper. The pathway portion
is written on a predesigned template (Table 3) for consistency. Students complete the assignment in 1 month
from the class date.

Table 3. Clinical Pathway: Hospital or Homecare

Evaluation of Assignment
The assignment is graded on a point system that gives value to obtaining information and planning for care
across the continuum. A clinical pathway across the continuum (for hospitalbased care and home or ambulatory
care) is expected. All students were able to complete the assignment successfully. There were 23 papers, 10 of
which reflected the effort of a pair of students. Of the 33 students in the class, 44% received an A, 34% received a
B, and 12% received a C. It was apparent that further instruction was needed in identifying outcomes and
monitoring variances. The students often identified only complications as negative variances, omitting positive
variances.

Survey
In addition to evaluation of the assignment, an anonymous survey was designed by the faculty group and the
content was verified as relevant by all group members. The survey asks for written comments on each aspect of
the assignment as well as including general openended questions regarding the students' perspectives. This was
approved by the Human Subjects Committee at the university. The 10 questions and the related case
management concepts explored are listed in Table 4 The survey was given on completion of the written project.
Comments from the students were compiled by summarizing the responses to the questions. Two members of the
team independently compiled and compared the results for accuracy.

Table 4. Survey Questions

Seventeen of the 33 students (51%) responded to the survey; however, we believed the response rate
reflected the number of papers submitted (23), and some student pairs responded on one survey.

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Almost all the respondents (94%) stated that the assignment met the objective "to assist the student in
planning future healthcare by looking holistically at all phases of the healthcare system." The majority (82%)
believed the assignment helped them to see all aspects of care and learn case management concepts. Some
students (35%) noted they became more aware of tertiary aspects of care. Two respondents in particular stated
they became more aware of the costs of treatment.

Some students were frustrated by the lack of cooperation from insurance companies and hospital resources
when trying to obtain cost data. In terms of DRG information, students were able to obtain information from
hospital resources (58%), DRG handbooks (11%), and library references (11%). However, many hospitals were
hesitant to reveal any cost data. Unless the student had a personal connection with someone in medical records,
he or she had to be more creative at obtaining this information. Many had to make numerous phone calls. Only 23%
reported having no problem. This caused frustration for the students because they had to spend a great amount
of time sending letters and making phone calls. Two respondents reported begging for information. Current local
mergers may be related to the agencies' reluctance to share information.

Students were able to find information about outcome criteria from hospital resources (23%), publications,
national organizations, and articles (52%), insurance companies (11%), and personal experience and conversation
(11%). However, cost information was difficult to obtain, and many sources would not reveal their cost data. One
student stated, "The cost information was top secret; forprofit will not reveal costs!"

Students obtained information about community resources from other colleagues and personal experience
(47%), the literature (29%) phone books (17%), and community agencies (29%).

Information about insurance companies was not readily available to the students. Some insurance companies
were defensive and reluctant to give out any information (29%). Some would respond to written requests only and
provided only generic information (11%). Although most students finally received some information, they had to
have an inside connection or make several attempts (35%). One student could not obtain any information. Of the
information obtained, some students (35%) said it was helpful and some (29%) said it was not. One stated it was a
"big secret." Again, local competition and mergers may have influenced the reactions.

In terms of clinical pathways, 64% of the students were able to obtain readymade clinical pathways, 17%
found none, and 17% did not respond to the question. To construct their own clinical pathway, students used
personal experience, nursing books, or parts of other related pathways.

The survey question about developing outcomes to monitor variances had the widest variety of responses. As
noted above, the papers did not reflect a thorough understanding about identifying outcomes and variance
tracking: most considered variances synonymous with complications. Some students (17%) did not answer this
question. Seventeen percent of the students relied on their personal experience and knowledge to determine
the outcomes. They considered the patient's preexisting condition and common complications (23%) in developing
outcome measures. Others used various resources (41%) such as books, articles, and talking to others.

Three quarters of the students said they found the assignment valuable; 11% said it was somewhat valuable,
and 11% said it was not valuable due to the time and frustration involved in collecting the data. Some students
may not be comfortable with the time and energy required to use active learning strategies and prefer a more
passive model. However, we considered that the assignment was valuable in helping students learn how different
systems affect care and how case managers gather data. Students found the assignment interesting but also
frustrating.

Students reported the most positive aspect of the assignment was the introduction to clinical pathways (47%)
and learning concepts of case management (29%). A quarter of the students said they enjoyed working with others
to complete the project. Some of the students (17%) said they appreciated learning about the resources that were
available to patients and to themselves.

Students said the least positive aspect of the assignment was the time involved (41%) and the difficulty
getting information (41%). One student (aptly) reported, "I felt like a spy in enemy territory when it came to the
insurance companies."

Implications

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This learning module is successful in introducing students to managed care and case management concepts.
Using these concepts, students identify the continuum of care for the chosen population. They develop a clear
understanding of how the clinical pathway establishes guidelines to follow, in an effort to meet managed care
demands. The value to students is an increased awareness of all phases of the illnesswellness continuum,
including cost of care. The students previously were immersed only in the tasks of the level of care in their own
work setting.

Instituting active learning strategies to learn case management requires active involvement in the process of
learning. Students increase their skills in information gathering from experts and library and Internet resources.
Students also engage in active learning strategies such as negotiation and networking. Some students do not like
this, because traditional methods of learning are more passive and do not require the students to be creative and
to apply concepts actively. These students need an increase in interaction and guidance with faculty facilitators.
Some students who worked on the project together commented about their positive working relationship, which
helped them complete the assignment.

During the assignment, the students confronted barriers to obtaining the information required to complete
the project. One area of difficulty for the students was learning how to obtain information from sources other than
traditional ones. Students need to enhance their communication skills to negotiate for information not found in
textbooks. They need to use creative thinking to communicate effectively through letters and telephone calls.

If this assignment is used with experienced RN students with knowledge of standards of care in a clinical
setting, they can apply this knowledge in information gathering. Their expertise helps them in developing a
pathway, especially when a prewritten plan is not available. However, if this assignment is used for generic
baccalaureate students who are novices and lack expert knowledge, modifications should be made.

This assignment should be used as a seniorlevel leadership exercise due to the high level of skills required in
research and collaboration. The assignment is for students who are in a clinical setting that provides access to
experts (in the setting) who could help the students ascertain best practices and identify costs. Students could
also benefit from spending time with case managers or discharge planners who regularly deal with issues of
effective use of resources.

In addition to being used in an educational setting, this assignment could also be used in an institutional
setting to retrain or educate practicing RNs in concepts in case management. The clinical setting may facilitate
active learning and discovery by stressing networking for information. It may be difficult for nurses to see their
practice in terms of outcomes. This exercise may increase understanding of the changing milieu of healthcare and
the need to understand cost effectiveness and resource utilization. Nurses may develop skills in gathering
information from nontraditional sources. This may require an adjustment in the work setting by all partners in
care, thereby increasing awareness of economics, resources, and the value of interdisciplinary collaboration.
Strengthening awareness of costs on the part of RNs may be difficult, given the reaction of hospitals and payers,
but it is useful to sensitize students to organizational issues.

To improve this learning module and assignment, emphasis on the concept of quality indicators needs to be
strengthened, because it is a major premise of the clinical pathway and managed care concepts. Ethical and legal
aspects of case management were not included in this first pilot assignment but could be integrated by the use of
case studies. As managed care, case management, and clinical pathways become common in practice, ethical and
legal questions may emerge in the future.

This assignment produced an interesting situation in relation to increasing the students' awareness of cost
issues. Information on costs is necessary to understand cost effectiveness in caregiving practices and to determine
which company provides the best value for the healthcare dollar. Achieving the objectives relevant to costs was
difficult, given the lack of cooperation by insurance companies. Both healthcare and insurance organizations were
reluctant to share information they felt was proprietary. Because the insurance companies withheld information,
students had to learn skills of negotiation through trial and error. They experienced the political undercurrents
and untold fears of institutions.

It is important for faculty members and students to discuss these difficulties in obtaining cost data. Faculty
members can propose alternative strategiesfor example, students could "cost out" time and supplies in estimating
costs of care by telephoning pharmaceutical supply companies.

Quality indicators are an integral aspect of clinical pathways and managed care. Students often do not see the
connection between defining indicators and quality outcomes. Outcome identification has been used by nurses in
the context of goal achievement for decades; however, the implications of those outcomes have not been

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emphasized until the era of managed care. The ultimate goal of managed care is controlling costs while providing
highquality outcomes; this requires the application of outcome management. This is a new concept for the
practicing RN. Students need to increase their knowledge of clinical pathways for use in evaluating quality
outcomes, and we found that this part of the course needs to be developed further, spending more time on
outcome identification and variance analysis. The outcome measures demonstrate the worth of interventions as
well as providing financial information. These data may well substantiate the nurse's role and value in the plan of
care.

Some RNs have negative attitudes toward pathways. Some view them as a way to prescribe care given by
unlicensed personnel and to institute layoffs of RNs. However, we feel strongly that nursing judgment is essential
in using pathways effectively. Using their expert clinical judgment, nurses assess each patient's progress and
intervene when changes are required. Their role as patient advocate is strongly needed in today's costeffective
climate. Brown et al.5 found that clinical case management was resisted in a clinical setting until the staff
espoused a principle of "Our patient comes first." They also found that clinical and interpersonal skills are
necessary to promote collaboration. The patientcentered focus is the key to the competent coordination of care.
Clinical pathways are used as a tool to facilitate the measurement of quality.

Summary
This approach to teaching case management can be effective in an educational setting and potentially in
clinical settings. To practice in a managed care environment, nurses must understand managed care concepts and
clinical pathways. The AACN 6 predicts that nurses will become designers, managers, and coordinators of care.
The skills and content offered in this course help students toward this role development.

References
1. Aliotta SL. Components of a successful case management program. Man Care Q. 1996;4(2):3845. [Context Link]

2. AACN. American Association of Colleges of Nursing Position Paper: Vision of Baccalaureate and Graduate
Education: The Next Decade. Washington DC, 1996. [Context Link]

3. Bonwell CC, Eison, JA. Active Learning: Creating Excitement in the Classroom. ASHEERIC Higher Education
Report No. 1. Washington DC: The George Washington University, School of Education and Human Development,
1991. [Context Link]

4. Concept Media. HospitalBased Managed Care: Managed Care in the Acute Setting [video]. (Available from
Concept Media Inc., P.O. Box 19542, Irvine, CA, 926239849), 1996. [Context Link]

5. Brown L, Deckers C, Magallanes A, Quiamas D, Deschner S. Clinical case management: What works, what doesn't.
Nurs Manage. 1996;27(11):230. ArticleLinker Bibliographic Links [Context Link]

6. American Association of Colleges of Nursing. Essentials of Baccalaureate Education for Professional Nursing
Practice. Washington DC, 1998. [Context Link]

7. Ungvarski R. Adults and HIV/AIDS: Clinical considerations for care management. J Care Management. 1995;1(3):40
63.

8. Zander K. Managing Outcomes Through Collaborative Care: The Application of Caremapping and Case
Management. Chicago: American Hospital Publishing Association, 1995.

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