Chapter 25
Case Management
Copyright © 2020 by Elsevier Inc. All rights reserved.
1
Define continuity of care, care management, case management, care coordination, population health management, transitional care, integrated care, social determinants of health, and advocacy.
Describe the scope of practice, roles, and functions of a case manager.
Compare and contrast the nursing process with processes of case management and advocacy.
Objectives (1 of 2)
Copyright © 2020 by Elsevier Inc. All rights reserved.
2
2
Identify methods to manage conflict, as well as the process of achieving collaboration.
Define and explain the legal and ethical issues confronting case managers.
Objectives (2 of 2)
Copyright © 2020 by Elsevier Inc. All rights reserved.
3
3
Population management
Social mandate
Care management
Utilization management
Critical pathways
Disease management
Demand management
Definitions
Copyright © 2020 by Elsevier Inc. All rights reserved.
4
4
Case management and the nursing process
Characteristics and roles
Knowledge and skill requisites
Tools of case managers
Historical evidence
Contemporary evidence
Concepts of Case Management
Copyright © 2020 by Elsevier Inc. All rights reserved.
5
5
Assessment
Diagnosis
Planning for outcomes
Implementation
Assessment
Case Management and the Nursing Process
Copyright © 2020 by Elsevier Inc. All rights reserved.
6
See Table 25.1, The Nursing Process and Case Management.
6
Case Management Roles
Broker
Consultant
Coordinator
Educator
Facilitator
Liaison
Mentor
Monitor/reporter
Negotiator
Client advocate
Researcher
Standardization monitor
Systems allocator
Copyright © 2020 by Elsevier Inc. All rights reserved.
7
See Box 25.1, Case Manager Roles, for descriptions of these roles.
7
Factors That Demand Case Management Attention
Copyright © 2020 by Elsevier Inc. All rights reserved.
8
Fig. 25.4: Factors that require the attention of the nurse and client in the case management process
8
Knowledge and Skill Requisites
Standards of practice for case management
Evidence-based practice guidelines
Knowledge of the health care financial environment
Clinical knowledge, skill, and maturity
Care resources
Transition planning
Management skills
Teaching, counseling, and education skills
Program Assessment and research
Performance improvement techniques
Peer consultation and Assessment
Requirements of eligibility and benefit parameters by third-party payers
Legal and ethical issues
Information management systems
Health care legislation/policy
Technical information skills
Outcomes management and applied research
Copyright © 2020 by Elsevier Inc. All rights reserved.
9
See Box 25.2 for an expanded list of knowledge and skill requisites.
9
Six “rights” of case management
Right care
Right time
Right provider
Right setting
Right price/value
Right outcomes
Tools of Case Managers (1 of 2)
Copyright © 2020 by Elsevier Inc. All rights reserved.
10
10
Three tools
Case management plans
Standards of client care and nursing practice
Clinical guidelines
Evidence-based practices
Critical path development gave way to care maps
Disease management
Focus: the natural progression of a disease in high-risk populations
Life care planning
Needs of a client for catastrophic or chronic disease over a life span
Technology driven
Tools of Case Managers (2 of 2)
Copyright © 2020 by Elsevier Inc. All rights reserved.
11
Technology supports the delivery of processes used by the case manager. The technology sector is refining software in the areas of documentation, decision support, dashboard tools, predictive modeling, workflow automation, reporting capabilities, electronic health records, patient engagement strategies and social media, and remote monitoring.
11
Historical evidence
Taylor’s three models
Client focused
System focused
Social service
Contemporary evidence
Model of intensive case management (ICM)
Kolbasovshy (2009)
Reduced readmissions
CARE ONE program: reduced emergency room (ER) visits
2012 Study: decreased acute outpatient and inpatient admissions
Evidence-Based Examples of Case Management
Copyright © 2020 by Elsevier Inc. All rights reserved.
12
Client-focused models are concerned with the relationship between case manager and client to support continuity of care and to access providers of care.
System-focused models, in contrast, address the structure and processes of using the population-based tools of disease management and case management plans to offer care for client populations.
The social service models provide services to clients to Help them in living independently in the community and in maintaining their health by eliminating or reducing the need for hospital admissions or long-term care.
These models offer a solution to unnecessary health care expenses by reducing costs and accessing appropriate health care services.
12
Which model demonstrated a consistent reduction in ER visits, readmissions, and acute outpatient and inpatient admissions in multiple studies?
Social service
Client-focused
System-focused
Intensive case management
Quick Recall (1 of 2)
Copyright © 2020 by Elsevier Inc. All rights reserved.
13
13
Answer is D.
Intensive case management
Quick Recall (2 of 2)
Copyright © 2020 by Elsevier Inc. All rights reserved.
14
Model of intensive case management (ICM)
Reduced readmissions
Reduced ER visits
Reduced acute outpatient and inpatient admissions
How’d You Do?
Copyright © 2020 by Elsevier Inc. All rights reserved.
15
Advocacy
Conflict management
Collaboration
Essential Skills for Case Managers
Copyright © 2020 by Elsevier Inc. All rights reserved.
16
16
The advocacy role aims to achieve patient engagement.
By helping patients become invested in their health and care through programs that provide information and tools to empower them to take control and evaluate their care
Advocacy (1 of 2)
Copyright © 2020 by Elsevier Inc. All rights reserved.
17
The definition of nursing includes advocacy: “Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations” (ANA, 2010).
17
Process of advocacy
Promoting self-determination in clients
Informing:
Amplifying
Clarifying
Verifying
Supporting
Affirming
Illuminating values
Advocacy (2 of 2)
Copyright © 2020 by Elsevier Inc. All rights reserved.
18
Amplifying occurs between the nurse and the client to assess the needs and demands that will eventually frame the client’s decision. Information is exchanged from both viewpoints.
Clarifying is a process in which the nurse and client strive to understand meanings in a common way.
Verifying is the process used by the nurse advocate to establish accuracy and reality.
The second major process, supporting, involves upholding a client’s right to make a choice and to act on it.
The third process in the advocacy role is affirming. It is based on an advocate’s belief that a client’s decision is consistent with the client’s values and goals.
18
Allocation roles in nursing
Triage
Gatekeeping
Rationing
Systems-level demands
Budget decisions
Staffing assignments
Clinical level demands
Implementing treatment protocols
Advocacy can conflict with allocation.
Limited resources contribute to this conflict.
Allocation and Advocacy
Copyright © 2020 by Elsevier Inc. All rights reserved.
19
19
Negotiation outcomes
Distributive outcomes
One party gains
Integrative outcomes
Mutual advantages override individual gains
Negotiation stages
Prenegotiating
Negotiating
Aftermath
Conflict Management
Copyright © 2020 by Elsevier Inc. All rights reserved.
20
Negotiating is a strategic process used to move conflicting parties toward an outcome. The outcome can vary from one in which one party gains benefit at the other’s expense (distributive outcomes) or in which mutual advantages override individual gains (integrative outcomes).
20
Establish issues and agenda.
Advance demands and uncover interests.
Bargain and discover new options.
Work out an agreement.
Negotiation Phases
Copyright © 2020 by Elsevier Inc. All rights reserved.
21
21
Communication is essential but not sufficient.
Joint decision making valued
However, one member should be accountable.
Handling competing expectations
Collaboration (1 of 2)
Copyright © 2020 by Elsevier Inc. All rights reserved.
22
22
Collaboration (2 of 2)
Goal: to amplify, clarify, and verify all team members’ points of view
Copyright © 2020 by Elsevier Inc. All rights reserved.
23
23
Legal issues
Ethical issues
Issues in Case Management
Copyright © 2020 by Elsevier Inc. All rights reserved.
24
24
Liability for managing care
Negligent referrals
Experimental treatment and technology
Confidentiality/security
Fraud and abuse
Legal Issues
Copyright © 2020 by Elsevier Inc. All rights reserved.
25
25
Autonomy
Beneficence
Fidelity
Justice
Nonmaleficence
Veracity
Ethical Issues
Copyright © 2020 by Elsevier Inc. All rights reserved.
26
26
Collaboration
Tentative exploration Mutual
acknowledgment
Trust buildingAwareness
Commitment
Consensus
Co lle
gia lity
Amplification Negotiations
Staging of
Clarif i cation
Verifi cation
Com mun
icat ion
