Copyright © 2016 by Elsevier Inc. Chapter 22 Case Management Copyright © 2016 by Elsevier Inc.

Definitions Population management Social mandate Care management Utilization management Critical pathways Disease management Demand management Copyright © 2016 by Elsevier Inc.

Evidence-Based Knowledge of Case Managers Figure 22-1 shows evidence-based knowledge of case managers from disciplines of nursing, social work, and rehabilitation counseling. It also illustrates the unified knowledge domains for professionals in case management and emphasizes the fluidity of common knowledge used by case managers regardless of discipline. Copyright © 2016 by Elsevier Inc.

Case Management Model Figure 22-2 (Coggeshall, 2008) illustrates a case management model pyramid that recognizes the tenets of risk stratification and case finding, coordination, and ultimately case management of a smaller proportion of patients in the population. This model recognizes the interchange of public health and populations at risk for service intensity due to economic or care integration needs. Copyright © 2016 by Elsevier Inc.

Concepts of Case Management Case management and the nursing process Characteristics and roles Knowledge and skill requisites Tools of case managers Historical evidence Contemporary evidence Copyright © 2016 by Elsevier Inc.

Case Management and the Nursing Process Assessment Diagnosis Planning for outcomes Implementation Evaluation See Table 22-1, The Nursing Process and Case Management. Copyright © 2016 by Elsevier Inc.

Continuum of Care Case Management Model Figure 22-3 Copyright © 2016 by Elsevier Inc.

Case Management Roles Negotiator Broker Client advocate Consultant Researcher Standardization monitor Systems allocator Broker Consultant Coordinator Educator Facilitator Liaison Mentor Monitor/reporter See Box 22-1, Case Manager Roles, for descriptions of these roles. Copyright © 2016 by Elsevier Inc.

Factors That Demand Case Management Attention Figure 22-4: Factors that require the attention of the nurse and client in the case management process Copyright © 2016 by Elsevier Inc.

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 evaluation and research Performance improvement techniques Peer consultation and evaluation 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 See Box 22-2 for an expanded list of knowledge and skill requisites. Copyright © 2016 by Elsevier Inc.

Tools of Case Managers Six “rights” of case management Right care Right time Right provider Right setting Right price/value Right outcomes Copyright © 2016 by Elsevier Inc.

Tools of Case Managers (Cont.) 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 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. Copyright © 2016 by Elsevier Inc.

Evidence-Based Examples of Case Management 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 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 assist 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. Copyright © 2016 by Elsevier Inc.

Essential Skills for Case Managers Advocacy Conflict management Collaboration Copyright © 2016 by Elsevier Inc.

Advocacy 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 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). Copyright © 2016 by Elsevier Inc.

Advocacy (Cont.) Process of advocacy Promoting self-determination in clients Informing: Amplifying Clarifying Verifying Supporting Affirming Illuminating values 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. Copyright © 2016 by Elsevier Inc.

Nursing Process Versus Advocacy Process Assessment/diagnosis Information exchange; illuminate values Planning/outcome Generate alternatives; prioritize Implementation Decision making; support and reassure client Evaluation Affirmation; evaluation; reformulation Copyright © 2016 by Elsevier Inc.

Allocation and Advocacy 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. Copyright © 2016 by Elsevier Inc.

Conflict Management Negotiation outcomes Negotiation stages Distributive outcomes One party gains Integrative outcomes Mutual advantages override individual gains Negotiation stages Prenegotiating Negotiating Aftermath 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). Copyright © 2016 by Elsevier Inc.

Negotiation Phases Establish issues and agenda. Advance demands and uncover interests. Bargain and discover new options. Work out an agreement. Copyright © 2016 by Elsevier Inc.

Collaboration Communication is essential but not sufficient. Joint decision making valued However, one member should be accountable. Handling competing expectations Copyright © 2016 by Elsevier Inc.

Collaboration (Cont.) Goal: to amplify, clarify, and verify all team members’ points of view Copyright © 2016 by Elsevier Inc.

Issues in Case Management Legal issues Ethical issues Copyright © 2016 by Elsevier Inc.

Legal Issues Liability for managing care Negligent referrals Experimental treatment and technology Confidentiality/security Fraud and abuse Copyright © 2016 by Elsevier Inc.

Ethical Issues Autonomy Beneficence Fidelity Justice Nonmaleficence Veracity Copyright © 2016 by Elsevier Inc.