1. Case Management Processes

2. Assessment Functions of Case Management Direct Outcomes of Case Management End Outcomes of the Health System Planning Facilitation Advocacy Patient Knowledge Patient Involvement in Care Patient Empowerment Patient Adherence Coordination of Care Quality of Care Cost of Care Health Outcomes Source: Council for Case Management Accountability, 1999 Spectrum of Accountability

3. Stages Of The Case Management Process: A.Case Selection B.Assessment or Problem Identification C.Development and Coordination of the Case Plan D.Implementation of the Plan E.Evaluation and Follow-Up F.Continuous Monitoring, Reassessing, Re- evaluation

4. A. Case Selection 1.A process of evaluating individuals referred for case management services based on an established set of criteria. 2.Criteria enable case manager to determine whether the patient needs case management services and the services that will be needed. 3.No single condition or diagnosis, with the exception of reportable events, is automatically a problem that necessitates full case management services.

5. A. Case Selection 4.Determines the need for case management a.Requires at least a cursory assessment to determine needs of patient b.All patient do not need a case manager. c.Case management may not be necessary if i.Patient meets intensity of services or severity of illness criteria ii.No major discharge barriers are identified iii.If readmission is not a concern iv.There are no financial barriers present d.Case management may be necessary when there are i.Complex medical issues or comorbidities ii.Complex discharge needs iii.Complex social issues

6. A. Case Selection 7.Establishing selection criteria a.May be specific to the goals of the organization (ie., rehabilitation potential, ventilator dependent) b.criteria include but are not limited to the following items: i.Lives alone or with someone with a disability ii.Age over 65 years iii.Readmission within 15 days or Repeated admissions to acute care iv.Overdose or Alcohol and drug abuse v.Chronic mental illness or Alzheimer's dementia vi.Noncompliance or Uncooperative, or aggressive behavior vii.Suspected child or elder abuse and neglect viii.Homelessness or Poor living environment ix.Residence in rural community with limited or nonexitent services x.Limited financial resources or No or inadequate health insurance xi.Single parent xii.Dependent in activities of daily living

7. B. Assessment or Problem Identification 1.A thorough assessment must be done at this point in order to determine the needs of the patient, particularly as they relate to the discharge plan. 2.Identification of actual and potential problems are identified and goals are established. 3.Sources of assessment data: a)Patient b)Family physician c)Office and hospital medical records d)Ancillary staff e)Family f)Employer

8. B. Assessment or Problem Identification 4.Patient data to be collected a)Patient history and demographics b)Current medical status c)Nutritional status d)Medication assessment e)Financial assessment f)Functional assessment g)Environmental factors h)Psychosocial assessment i)Cultural and religious diversity

9. C. Development and Coordination of the Case Plan 1.Establishing goals 2.Prioritizing needs and goals 3.Service planning and resource allocation

10. D. Implementation of the Plan 1.Case managers within a facility (internal) a)Before discharge b)The day of discharge 2.Case managers outside of the facility (external) a)Initial checks b)Intermediate checks c)Case closure

11. D. Implementation of the Plan 3.Family needs: a)Must be assessed by the case manager and addressed with the patient's family members to help them cope with illness and hospitalization b)Specific needs of the family have been identified in numerous re search studies. c)The need for hope and the need for information about their family member's condition were seen as the most important of all the needs identified. d)A key role of the case manager is communicating accurate information to the family to enable then to make informed decisions, thereby assisting them to gain understanding and a feeling of control over a difficult situation.

12. E. Evaluation and Follow-Up 1.Depends on the type of case management employed 2.Case evaluation 3.Case management outcomes

13. F. Continuous Monitoring, Reassessing, Re-evaluation 1.Frequency depends on the site where case management is provided (ie., case management in a hospital may require more frequent follow up than for an individual in a private home or ECF). 2.Changes in medical status 3.Changes in social stability of the patient 4.Quality of care 5.Changes in functional capacity and mobility 6.Evolving educational needs 7.Termination of case management services

14. Care Management Processes in Physician Organizations (N = 1,040) ProcessDiabetesAsthmaCHF 1. Case management39.7 43.4 2. Feedback to physicians 24.1 30.5 3. Disease registries31.2 34.8 4. Clinical guidelines with reminders 33.9 27.7 Practices using all 412.77.6%8.6 Casalino, L. et al. (2003). External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. Journal of the American Medical Association.