Chapter 13 Case Management Ann H. Cary Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Introduction Case management is a strategy that is used in an overarching process called care management Care management is an enduring process in which a population manager establishes systems and monitors the health status, resources, and outcomes for an aggregate Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Building Blocks Used by Case Managers Risk analysis Data mapping Data monitoring for health processes, indicators, and unexpected illnesses Epidemiologic investigation of unexpected illnesses Multidisciplinary development of action plans and programs Identifying case management triggers or events that promote earlier referrals of high-risk clients when prevention can have dramatic results Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Definitions of Case Management Care management: a program or process that establishes systems; monitors the health status of individuals, families, and/or groups; and develops planning and intervention activities and targeted evaluation outcomes for the client and program Strategies: use management; critical paths; disease management; demand management; and case management Case management: includes the activities implemented with individual clients in the system Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Definitions of Case Management, cont’d. Case manager builds on the basic functions of the traditional role and adapts new competencies for managing transition from one part of system to another or to home Coordinating: conscious activity of assembling and directing the work efforts of a group of health providers so that they can function harmoniously in the attainment of the objective of client care Advocacy: activities for the purpose of protecting the rights of others while supporting the client’s responsibility for self-determination; involves informing, supporting, and affirming a client’s self-determination in health care decisions Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Management and the Nursing Process Case management is complex because of the coordinating activities of multiple providers, payers, and settings throughout a client’s continuum of care More complex in rural settings Healthy People 2010 Through a nurse’s case management activities, general community weaknesses in quality and quantity of health services are often discovered Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Managers: Characteristics, Roles, Knowledge, Skill Requirements Characteristics and roles Can be labor intensive, time consuming, and costly Knowledge and skill requirements Knowledge of community resources and financing methods Written and oral communication and documentation skills Negotiation and conflict-resolution skills Critical-thinking processes to identify and prioritize problems for the provider and client views Identification of best resources for the desired outcomes Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Tools of Case Managers Case management plans Core foundations of the plans include: Standards of client care Standards of nursing practice Standards of practice for case management CareMaps Tool developed by Zander showing cause and effect and identifying expected client/family and staff behaviors against a timeline Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Advocacy Skills for Case Management Nurse advocates make the client’s rights the priority Aim to promote self-determination in a client group Process of advocacy Informing Supporting Affirming Systematic problem solving Illuminating values Generating alternatives Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Conflict Management Skills for Case Management Case managers help clients manage conflicting needs and scarce resources “Mutual benefit with limited loss for everyone” is the goal of conflict management Techniques Using a range of active communication skills directed toward learning all parties’ needs and desires Detecting areas of agreement and disagreement Determining abilities to collaborate Assisting in discovering alternatives and valuable activities for reaching a goal Negotiating, assertiveness, and cooperation Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Collaboration Skills for Case Management Goal: promote respect, understanding, and accuracy of communication of all team members’ points of view Need knowledge and skills about: Clients Health status Resources Treatments Community providers Clients’ and families’ complex needs Intra-/interpersonal, medical, nursing, and social dimensions Team member and leadership skills Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Issues in Case Management Legal issues Liability concerns of case managers exist when the following conditions are met: The provider had a duty to provide reasonable care A breach occurred through an act or omission to act The act or omission caused injury or damage to the client Ethical issues Autonomy, beneficence, and justice Copyright © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.