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Critical Care Case ManagementKelly PriceFerris State University Case ManagementChanges in the healthcare system affect the types of services and health care provided to people. Unfortunately in this country, healthcare is rationed by people’s ability to pay. According to Maurer and Smith (2009), a person’s financial status affects the quantity and quality of care he or she receives. The development of a cost-effective quality health service is one of the challenges the health care industry faces. One such system of case management is used as a model of nursing care delivery in critical care settings (Fox, Anderson, & McKinley, 1996).According to Fox, Anderson, and McKinley (1996), “Case management is designed to promote patient and customer satisfaction through the use of clinically expert case managers who can balance patient and family needs with efficacious and cost-effective use of resources while continually monitoring, evaluating, and modifying the treatment plan to achieve optimal patient outcomes” (p. 1). The main duties of case management include devising care plans such as referrals, medication doses, administering therapies and treatments, evaluating results and the plan’s effectiveness (Chiedozie, 2010).Pegg Osowski is a critical care case manager at Borgess Medical Center in Kalamazoo, Michigan. Borgess has four critical care units each with eight beds. Pegg oversees all of these units and patients with case management. Ms. Osowski has twenty years of bedside nursing care in critical care and emergency. Also she has been in case management for over twenty years (P. Osowski, personal communication, February 3, 2011).Job DutiesThe job duties of a critical care case manager include utilization review, discharge planning, analyzing data, quality improvement and decreasing length of stay. Pegg Osowski states that “Borgess Medical Center is going through a restructuring phase and there are now new positions that just do utilization review and data analysis” (P. Osowski, personal communication, February 3, 2011). Her job requirements are mainly discharge planning, quality improvement and decreasing length of stay. Her caseload varies between twenty-three to thirty-one cases and she does more face to face discharge planning with the patient, families, and physicians (P. Osowski, personal communication, February, 3, 2011). Everyday Ms. Osowski meets with the critical care assistant director and discusses which patients are ready to be discharged and who is not. She uses the patient’s physiology and Apache score to help determine a discharged patient. In addition she discusses the patient’s prognosis with the critical care intensivist. In addition, Ms. Osowski attends physician rounds with the nurses and discusses the patient’s chart and progress. On Fridays, Ms. Osowski meets with a representative from Pharmacy, Respiratory Therapy, Infection Control, Critical Care Education and the Critical Care Medical Director to discuss length of stay and ways to decrease barriers (P. Osowski, personal communication, February 3, 2011).During my interview, I asked Pegg Osowski about the process of determining length of stay and the diagnostic-related group (DRG) system. According to Maurer and Smith (2009), this prospective payment system was initiated by the Medicare program and consists of a predetermined fee structure for services provided by hospitals for a list over 468 diagnoses. The length of stay for each diagnosis is preset and so is the cost of reimbursement. For example, a patient who is admitted for a stroke and no complications is expected to stay a certain number of days and be transferred to a rehabilitation facility. If the hospital can treat and discharge the patient earlier than the prescribed length of stay, the hospital will make more money, thus more profit. On the other hand if the patient stays beyond the length of stay, the hospital loses money and loses profit (Maurer & Smith, 2009). Pegg Osowski states in “critical care patients with tracheostomies who have had a major surgery must stay thirty-three days in order for the hospital to be reimbursed and those who receive percutaneous tracheostomy must stay twenty-three days” (P. Osowski, personal communication, February 3, 2011). In order to reduce the length of stay so that the hospital makes a profit, physicians are doing tracheostomies earlier (P. Osowski, personal communication, February 3, 2011). Ms. Osowski reports to a director or vice president. She does not supervise anyone. Currently her level of education consists of a Bachelor’s of Nursing and a Master’s degree in Public Administration in Healthcare. When asked why she went into case management, Ms. Osowski’s response “she simply wanted to help those who left the hospital” (P. Osowski, personal communication, February 3, 2011).CollaborationAs a nurse care manager it is vital to collaborate with other healthcare professionals in order to achieve and evaluate expected outcomes of patients. When Ms. Osowksi first started in case management she collaborated with what were called interdisciplinary teams. Now she explains that in order to achieve the goals of her job such as decreased length of stay and improved patient outcomes she uses multiple services and disciplines within the hospital and community (P. Osowski, February, 3, 2011). Every day she collaborates with the medical intensivists and trauma team, pharmacy, bedside nurses, physical therapy, occupational therapy, respiratory therapy, social work, palliative care, spiritual care, dietary and the lab department. In addition, she works with care managers from insurance companies and medical coding specialists to ensure that documentation is up to date, correct, and concrete.In regards to working with bedside nurses and nurse managers, Ms. Osowski attends a one on one meeting with the critical care assistant director everyday in the morning to see who is going to be discharged and who has been delayed. Furthermore, she attends critical care rounds with the bedside nurses and physicians and discusses their care and prognosis (P. Osowski, February 3, 2011).Future and ChangeAccording to Yoder-Wise (2011) “the development of collaborative models of healthcare management incorporating nurses, social workers, and case manager has demonstrated significant cost savings” (p. 261). Borgess Medical Center has developed departments of healthcare case management. For example, Pegg Osowski works with the “medically complex”, where as a social worker works with the “socially complex” and there is a separate utilization review department (Yoder-Wise, 2011).In the last three to five years technology has changed Pegg Osowski’s role as a critical care case manager in that when she first started case management her job duties entailed utilization review, discharge planning, and analyzing data. Now her main job duties include discharge planning and decreased length of stay. Furthermore Ms. Osowski stated “when she first started working as a critical care case manager, for billing purposes with insurance and Medicaid, she worked on five different computer systems” (P. Osowski, personal communication, February 3, 2011). Today she works on a single system called Medipak for billing, Cerner for charting, and Solcom which allows healthcare professionals to look up previous visits.When asked about the future and the role of case management, Ms. Osowski stated, “ I would like to see national healthcare and be rid of Health managed organizations (HMO) and I think if there was more preventative care and medicine there wouldn’t be as many poor patient outcomes” (P. Osowski, 2011). Ms. Osowski believes there will always be a need for case managers’ especially critical care case managers due to patients needing rehab and choices about home care or to enter an acute care facility. She does know that her caseloads have increased throughout the years, but as a patient advocate and facilitator she is doing what she loves, helping others.ReferencesChiedozie, A. (2010). Job description of a nurse case manager. Retrieved February 16, 2011 from , S., Anderson, B.J., & McKinley, W.O. (1996). Case management and critical pathways: links to quality care for persons with spinal cord injury. American Rehabilitation. Retrieved February 16, 2011 from /?tag=content;col.Maurer, F.A. & Smith, C.M. (2009). Community public health nursing practice: Health for families and populations (4th ed). St. Louis, MO: Elsevier Inc.Yoder-Wise, P.S. (2011). Leading and Managing in Nursing. (5th ed). St. Louis, MO: Elsevier Inc.Non-Clinical Interview: 100 ?(out of 100) Kelly: Well done on your assignment...you have addressed all of the requirements and clearly supported your ideas with scholarly sources. Thanks, Eppie ................
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