Introduction to Care/Case Management
Introduction to Care/Case Management
Teresa J. Kelechi, PhD, RNCS
January 15, 2003
Objectives:
Following this class, the student will be able to:
1. discuss the differences between care management and case management
2. describe three roles of the case/care manager
3. describe a process for developing a case/care management model
References:
American Accreditation Healthcare Commission. (2002, April). Disease management standards. Retrieved April 17, 2002, from .
Ball, R. S. (2000). Nurse case managers and the internet. Lippincott’s Case Management, 5(5), 174-183.
Carneal, G., & D-Andrea, G. (2001). Defining the parameters of case management in a managed care setting. Managed Care Quarterly, 9, 55-59.
Goode, C. J., & Piedalue, F. (1999). Evidence-based clinical practice. Journal of Nursing Administration, 29(6), 15-21.
Goode, C. J., et al (2000). Outcomes from use of an evidence-based practice guideline. Nursing Economics, 18(4), 202-207.
Lee, D. T. F., et al (1998). Case management: A review of the definitions and practices. Journal of Advanced Nursing, 27(5), 933-939.
McCulloch, D. K., Price, M. J., Hindmarsh, M, & Wagner, E. H. (2000). Improvement in diabetes care using an integrated population-based approach in a primary care setting. Disease Management, 3(2), 75-82.
Standard, R. P. (1999). The effects of training in a strengths model of case management on client outcomes in a community mental health center. Community Mental Health Journal, 35(2), 169-179.
Glossary of terms: terms
Evolution
Began in 1990’s with shifts in:
Reimbursement – capitation, HMOs, PPOs
Ethical/legal issues – “defensive” medicine
Acute to community/home/long-term care
Health disparities/diminished access to care
Market competition (University Medical Associates, Lowcountry Medical Associates)
Paradigm shifts
Primary health care
Community
“seamless” health care delivery
Wellness and prevention foci
Non-medical determinants
Socioeconomic status
Housing
nutrition
Shifts continued
Family violence
Public health
Bioterrorism
Financial models – incentives for aggregates
Population-based capitation
Contractual arrangements for group services
Partnerships
Challenges for case management
Development of population-based health management
Provide services for individuals, communities, special populations, institutions, health plans
Address health status, quality of life, effectiveness of health care utilization
Challenges
Defining the consumer
The ones who purchase health care
The ones who pay for health care
The ones who provide health care
Who are the “partners” in care?
What is the “health care delivery system”?
Reconfiguration
From managing costs to managing care
“2020” Vision: Health in the 21st Century”
“Health People 2010 Program”
From managing individuals to managing populations
From nursing to interdisciplinary integration and coordination
What is nursing case management?
Since 1985 (DRG’s)
Professional practice model
Focus on quality, outcomes-focused care while containing costs
Appropriate length of stay
Appropriate use of resources based on specific case types
Integration and coordination of clinical services
What is case management?
Monitors the use of patient care resources
Supports collaborative practice and continuity of care
Enhances patient and provider satisfaction
Model varied
Setting
Characteristics dependent on the discipline that employs its
Personnel and staff mix (APN’s vs. RN’s)
What is nursing case management?
Collaborative
Focuses on the coordination, integration, and direct delivery of patient services
Places internal controls on the resources used for care
Requires methods for monitoring patient care activity and resource distribution
Monitoring
Critical paths (a description of patient care requirements in outline form)
Case management plans (similar to the standard nursing care plan but adapted to nursing case management outcome standards)
Multidisciplinary action plans (MAPs)
Approaches or model
Within the walls (WWW) – acute care
Beyond the walls (BTW) – outpatient/community-based, HMO
Population-based disease management
Environment-based population management
Dialysis clinics
School health clinics
Current Issues
Need for documentation on measureable outcomes of nursing case management interventions
Data reporting processes
Systematic tracking (readmissions)
Standardized language and documentation systems
Issues
Education and competencies
Compliance, regulation, and reimbursement issues
Ethical considerations
Types of case management
Targets
Specific groups
Frail elderly
Chronically ill who are functionally or emotionally challenged
Long-term care clients
Social case management
Emphasis on long-term care community
Purpose to delay hospitalization
Addresses health a social needs
Focuses on independence through family and community
Based on multidisciplinary approach
Services might include homemaking, meals
Primary Care Case Management
Role of gatekeeper based on medical model
Based on treatment of health problem
Physician-driven
Regulates resource use to assure cost-effectiveness
HMOs
Services needs varied; depends on health problems
Medical-Social Case Management
Focuses on long-term care population at risk for hospitalization
Combines available resource utilization with added services not traditionally covered by health insurance
Transitional care
Various models
Medical-Social Models
Generalist – acts as broker – does intake, coordination, and evaluation
Primary case manager (CM) – therapeutic relationship – psych CNS
Interdisciplinary team – functions divided among team members with specific expertise and specialization
Medical-Social Models
Private case management – outside publicly-funded arena
Services include coordination of services, social, functional and financial; mental health assessment and counseling; referral, monitoring and evaluation
For elderly, home health care, homemaker and personal care services; family and legal counseling; physical therapy
Private case managers
More individualized services
Accessible on off hours, weekends, and holidays
Rates based on hourly or set rates for out-of-pocket services, private insurance
Components of case management
Client identification and outreach
Individual assessment and diagnosis
Service planning and resource identification
Linking clients to needed services
Service implementation and coordination
Monitoring service delivery
Advocacy
Evaluation
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