Chapter 9 Case Management Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.

Case Management … “… is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes.” – The Case Management Society of America (2009) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 2

Nursing Case Management … … is “a dynamic and systematic collaborative approach to provide and coordinate health care services to a defined population. The framework includes five components: assessment, planning, implementation, evaluation and interaction.” – American Nurses Credentialing Center, ANA Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 3

Care Management Overall goal: Improve the coordination of services provided to clients who are enrolled in a care management program.  A collaborative process  An emerging concept that is…  evidence based  patient centered  clinical care focused Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 4

Care Coordination  Target chronically ill persons at risk for adverse outcomes and expensive care  Identify full range of problems that increase patients’ risk of adverse health events  Educate in self-care, optimization of treatment, and integration of care  Monitor patients for progress and early signs of problems  Hope to raise quality of care, improve health outcomes, and reduce need for costly hospitalizations and medical care Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 5

Patient-Centered Medical Homes  Seven characteristics:  Patient’s relationship with primary care physician  Physician-led, team-based care  “Whole persons” require comprehensive care at various stages of life  Integration and coordination of care  Quality and safety  Improved access to care  Payment system that accurately reflects the efforts and care provided by the team Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 6

Purposes of Case Management  Client centered  Help the client through a complex, fragmented, and often confusing health care delivery system and achieve specific client-centered goals.  System-centered  Recognizes that resources are finite  Promote cost-effective, high-quality care Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 7

Possible Case Management Functions  Identifying the target population  Determining screening and eligibility  Arranging services  Monitoring and follow- up  Assessing  Planning care  Reassessing  Helping clients through a complex, fragmented health care system  Care coordination and continuity Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 8

Case Managers  Must have appropriate educational background  A minimum skill level is needed to ensure success in the role  Certification as a case manager is available  Case Management Association of America (CMSA)  American Nurses Credentialing Center (ANCC) Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 9

Role Functions of Case Managers (CMSA, 2002)  Essential activities of case management  Assessment  Planning  Facilitation  Advocacy  Collaboration Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 10

Case Management in Community Health  Community case management models  Public health clinic settings  Occupational health settings  High-risk clinic settings  Clients with chronic diseases  Home health and hospice  Case management research  International settings Copyright © 2015, 2011, 2007, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 11