Case management
Communication
NOF Competency
The Nurse of the Future will interact with patients, families, and colleagues fostering mutual respect and shared decision making to enhance patient satisfaction and health outcomes
Course SLO
Integrate therapeutic communication and comprehensive, individualized teaching and/or discharge planning for patient needs with a focus on pediatric and/or medical-surgical patients with complex health needs.
Leadership
NOF Competency
The Nurse of the Future will influence the behavior of individuals or groups of individuals within their environment in a way that will facilitate the establishment and acquisition/achievement of shared goals.
Course SLO
Practice nursing leadership skills with patients and groups utilizing delegation, prioritization, and time management strategies.
Student Learning Outcomes:
• Explore resources available to assist the client with achieving or maintaining independence
• Assess the client’s need for materials and equipment (e.g., oxygen, suction machine, wound care supplies)
• Participate in providing cost effective care
• Plan individualized care for client based on need (e.g., client diagnosis, self-care ability, prescribed treatments)
• Provide client with information on discharge procedures to home, hospice, or community setting
• Initiate, evaluate, and update plan of care (e.g., care map, clinical pathway)
Knowledge acquisition and application:
The definition of case management and the role of the “case manager” vary greatly in the professional literature. As discussed with critical pathways in the integrated process entitled “Communication and Documentation”, case management is method of nursing care delivery, however, case management can also be used to describe the roles of people who work in health insurance companies, the roles of people, like social workers, who work in healthcare facilities to move clients along the continuum of care, and as of the many roles of that nurses have.
The registered nurse as a case manager entails the coordination of care, resource identification, the planning of services, referrals, and linking clients to the services that they need as based on their biological, emotional, and social needs as well as their spiritual and cultural preferences.
Registered nurses, as case managers of care:
Insure that client care is of high quality, effective, timely, complete and cost effective
Insure that all clients are provided with the care and services offered by not only the appropriate members of the nursing care team but, also, with members of the multidisciplinary healthcare team such as a physical rehabilitation team or a community home care team, for example. This aspect of case management is accomplished by connecting, referring and linking clients to the services that they need as based on the kinds of care and the levels of care that they need according to their current assessed needs.
Insure that all clients are provided with the material resources that they need to meet their current assessed needs. For example, the client may need a CPAP machine, a sequential pressure device, oxygen therapy and oxygen supplies, a suctioning machine and/or sterile wound care supplies including sterile dressings
Coordinate and continuously evaluate the timeliness, effectiveness and appropriateness of client care
Identify and implement immediate and effective actions if, and when, any deviations from the plan of care and/or poor patient outcomes occur
Insure that the client is at, or moved to, the appropriate level of care, as indicated by the current client’s status, so that appropriate care at the appropriate level of care can be provided and also to insure that insurance reimbursement for their necessary care and services is done
Case management, as previously mentioned, is also a formal method of nursing care delivery. In this context, case management can employ a number of different frameworks and models.
Exploring the Resources Available to Assist the Client with Achieving or Maintaining Independence
All available resources, including available human, material and financial resources, must be explored, identified and garnered in order to promote optimal patient care outcomes and to assist the client with achieving and maintaining their highest possible level of independence.
Nurses manage client care, as a case manager; strive to insure that the client receives the correct resources at the correct time and in a timely manner. When goal is not accomplished in an effective and timely manner, the healthcare facility loses money and/or optimal outcomes are not achieved.
All possible resources that could possibly assist the client with achieving and maintaining independence, as based on the assessment of the client and their current needs, are explored, after which the best possible and most feasible alternative(s) is (are) selected and employed. After this intervention, the registered nurse evaluates the successes or failures of these interventions in terms of how well they have facilitated client independence or any other expected or desired client outcome or goal or they have failed to do so. When expected outcomes are not achieved, the registered nurse determines the reason(s) behind this failure.
Assessing the Client’s Need for Materials and Equipment
After the client is fully assessed initially and then also reassessed in an ongoing manner, the nurse, as the manager of care determines which supplies, materials and equipment the client needs to meet their needs.
After this assessment and determination, the registered nurse then Insures that the client is provided with the material resources, including supplies and equipment that they need to meet their current assessed needs. For example, the client may need a CPAP machine, a sequential pressure device, oxygen therapy and oxygen supplies, a suctioning machine and/or sterile wound care supplies including sterile dressings
Participating in Providing Cost Effective Care
Nurses and other members of the healthcare team, often in a collaborative manner, plan care as based on is appropriateness, its cost effectiveness and its cost/benefit benefit ratio without compromising the quality of care and/or optimal positive outcomes of care. The challenge lies within. The nurse, and others, must select the treatments, interventions, and human and material resources that are the least costly and ALSO the most beneficial and the most appropriate.
Cost effective is defined as “giving the most profit or advantage in exchange for the amount of money that is spent” and the cost-benefit ratio is defined as the “comparison of the likely costs of a plan or project with the benefit it will bring, done in order to help make a decision”. Cost effective care and the care and services provided to clients with a good cost-benefit ratio is NOT always the least expensive and the least costly. Nonetheless, this care and services must be the least costly possible while still high quality and effective in terms of meeting the clients’ needs.
In the not too distant past, healthcare facilities, including hospitals and medical centers, were reimbursed for the services and care that they provided based on the cost associated with these services. This type of healthcare reimbursement was referred to as retrospective reimbursement. Under retrospective reimbursement, there was little or no reason or incentive to control and contain costs because insurance companies paid for all the provided care and services regardless of their associated costs. As healthcare costs continued to rise and spiral out of control, cost containment efforts led to the discontinuation of the retrospective reimbursement system and the rise of the prospective reimbursement system.
As the result of prospective reimbursement, healthcare facilities and healthcare providers no longer got reimbursed for all the care and services provided. Instead, they got, and remain to be, reimbursed at a fixed amount as determined by the client’s specific diagnosis related group (DRG). As a result of this retrospective reimbursement system, healthcare facilities that can successfully and effectively provide quality care that insures optimal outcomes with shortest possible lengths of stay and the fewest possible resources and care make more money than those with extended and prolonged lengths of stay and the use of unnecessary, abundant, and unlimited resources. Cost containment became, and remains to be, a high priority for healthcare organizations and healthcare providers.
Healthcare insurance companies, also referred to as third party payers, in our nation include governmental health care insurance and private healthcare insurance companies.
The United States Medicare program and the states’ administered Medicaid programs are the two governmental reimbursement programs. Medicaid reimburses healthcare costs for low income individuals, low income families, and chronically ill and disabled children. Medicaid is administered by the states. Medicare, under the U. S. Social Security Act, reimburses healthcare costs for older adults who are 65 years of age and older, as well as permanently disabled people and their dependents.
Private insurance companies differ in terms of their monthly premiums, their annual deductibles which the healthcare insurance policy holder must pay, their copayments which the healthcare insurance policy holder must pay, their covered services, and reimbursement rates.
Planning Individualized Care for the Client Based on Need
All care is planned as based on the needs of the unique individual and their needs, their diagnosis, their level of self care abilities, their strengths, their weaknesses, and treatments that are ordered and prescribed.
The planning process was previously detailed and discussed with the “Integrated Process: The Nursing Process”.
Providing the Client with Information on Discharge Procedures to the Home, Hospice, or Community Setting
Like initial planning, discharge planning should, and must, begin, as previously stated, at the time of the first client contact and/or immediately upon admission to a healthcare facility.
Discharge planning must reflect the needs of the client at the appropriate level of care along the continuum of care. For example, a discharge plan may include a discharge to the client’s personal home, to a physical rehabilitation center or a discharge to the client’s personal home with the services of a home health company. This planning can also include other discharges in the community such as a hospice and palliative care center, a long term care nursing home or an assisted living facility.
Failures to effectively plan discharges along the continuum of care fragment and jeopardize the well-being of the client. They are also quite costly and highly avoidable when continuous, ongoing assessments and discharge planning is complete and accurate.
As part of the discharge planning process, registered nurses in collaboration with others, use established medical necessity criteria to determine and to confirm that the client is being moved along the continuum of care at the appropriate level of care and also to confirm that the client is being provided with only those services and care that are consistent with these established criteria. Only care that meets these criteria will be paid for and reimbursed for.
Initiating, Evaluating, and Updating the Plan of Care
As previously stated, the purpose of a plan of care is to ensure that the client is getting appropriate, complete and timely care as based on the current needs and status of the client. For this reason, all clients must have a current plan of care that is initiated, evaluated in terms of its appropriateness, effectiveness, completeness and timeliness.
The plan of care, or care plan, whether or not it is a traditional care plan, a care map, or a critical pathway, MUST be updated and remain current as based on the client’s current needs.
Questions to answer :
After reading the information above, answer the following questions:
1. You are the nurse who is caring for a patient who has a tracheostomy and is being discharged. How would you collaborate with the Nurse Case Manager (CM)? Identify how the Nurse CM would assist with this particular type of patient.
2. You are the nurse who is caring for a patient who is homeless and has a new diagnosis of Diabetes Mellitus. How would you collaborate with the Nurse Case Manager? Identify how the Nurse CM would assist with this particular type of patient.
3. You are the nurse who is caring for a patient who has suffered multiple bone fractures and a head injury from a motor vehicle accident. How would you collaborate with the Nurse Case Manager? Identify how the Nurse CM would assist with this particular type of patient.
