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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