Family Plan of Care and Interventionby Case Management Approach

in Home Care

Sheizi Prista Sari

General Issues

Four major changes in end-of-life care

1. Care should attend to body, mind, and spirit.

2. Death must not be a taboo topic.3. Medical technology should be used

with discretion.4. Clients have a right to truthful

discussion and involvement in treatment decisions.

Future of Home Health and Hospice

• Transformation into a community-based long-term care system; cost containment

• Change in the model for service provision to address those living with disabling and terminal illness

• Change in focus for hospice to be based on client choice and reality of terminal diagnosis

• Need for ongoing case management• Increased education and supportive networks for

clients and family caregivers• Telehealth and home monitoring

Is Case Management?

(https://www.google.com/pictures)

• a specific approach for the coordination of health services

• a general term referring to the facilitation of treatment plans to assure the appropriate medical care is provided to disabled, ill or injured individuals

Case Management is a collaborative client-driven strategy for the provision of quality

health and support services through the effective and efficient use of available resources in order to support the client's achievement of

goals related to healthy life and living in the context of the person and their ability

(Canadian Home Care Association)

• Case management is not an independent function or designated to a specific discipline. Rather, it is a strategy or process undertaken by all health care professionals; and indeed a strategy that clients themselves employ to varying degrees depending on their context and position within the health care continuum.

• Case management is a strategy for maximizing client wellness and autonomy, within their context, through advocacy, communication, education, identification of service resources and service facilitation.

• Case management is built into all health professionals' scope of practice. The case manager, as part of a team, helps to identify appropriate services and options throughout the health care continuum, while balancing effective resource utilization in order to optimize value for the client and the system.

(Invitational Roundtable on Case Management, CHCA)

Characteristics

• Centered around and driven by the client/caregivers of all ages, respecting their choices, culture and values.

• Inclusive of strategies that enhance health promotion, illness prevention and risk mitigation through client education and emphasis on health promoting behaviors directed to the client's capacity for self management, self care.

• Purposeful incorporating evidence-based practice.• Respectful and collaborative, engaging the family and

community resources.

• Creative and innovative and requiring effective communication.

• Guided by an ethical framework.• Advocating on behalf of clients, and promoting

independence.• Responsive to client characteristics and changes in needs.• Incorporating of principles of population health and the

broad determinants of health.• Home care case management plays a role in some

transitions; in gate keeping, resource utilization, and resource management.

• Case management varies in intensity according to client needs and is shared between the health practitioner (which includes the case manager) and the client/caregivers.

Key elements of case management• Intake, which includes screening, prioritizing and

determining eligibility.• Assessment in order to determine client needs, wants and

goals.• Care and service planning, and coordination of services

which requires effective communication and liaising and considers cost-effectiveness.

• Care implementation.• Monitoring and evaluating outcomes from a patient and

population perspective.• Reassessment/revision of care plan to reflect cycles of care.• Disengagement, discharge, service completion.

Typical outcomes of case management• Delivering the appropriate service at the right time.• Decreased duplication of services.• Reduction of hospital/emergency utilization.• Improved client health status.• Decreased caregiver burden.• Improved connections across the system.• Improved disease management.• Avoidance of institutionalization.• Increased client participation in care.• Achievement of client goals.• Client satisfaction.

Point in Family Care Plan

• The family and HCP must define and agree on the health problem that is confronting the family member.

• The HCP presents and discusses options of care in a way that invites family questions.

• The family and HCP discuss pros and cons of options, including cost benefits, convenience, and financial costs.

• The family and HCP discuss values and preferences including ideas, concerns, and outcome expectations.

• The family and HCP discuss ability and confidence to follow through with steps or regimen for each option.

• Both the HCP and family should check and clarify for understanding the discussion and information shared.

• Both the HCP and family should reach a decision or defer decisions until an agreed-on, specified time.

• The HCP should follow up to track the outcome of the decision.

Four points willhelp the family break the plan of

care into action steps

1. We need the following type of help.2. We need the following information.3. We need the following supplies.4. We need to involve or tell the following

people about our family action plan.

Family Intervention

(1) providing direct care(2) removing barriers to needed services,(3) improving the capacity of the family toact on its own behalf and assume responsibility.(4) Being a case manager

“The types of interventions are limitless because they are designed with the family to meet their needs in the context of

their family story”

Case Manager

(Casemanagementstloius.com)

The case manager, as part of a team, helps to identify appropriate services and options throughout the health care

continuum, while balancing effective resource utilization in order to optimize

value for the client and the system.

Roles of Case Manager

• coordination of all services for patients in his/her geographic location

• new therapy staff orientation, and caseload coverage• establishes a visit schedule, coordinates with other

disciplines• oversees the progress of the patient from admission

through discharge, • assuming supervision of other therapists who may

visit the patient.• case conferencing with team members

Challenges

1. Provide a guide to creating context specific models for case management

2. Stimulate the development of case manager core competencies and influence human resources recruitment and retention strategies.

Related Journals

Case Management and Risk of Nursing Home Admission for OlderAdults in Home Care: Results of the AgeD in HOme Care Study

Graziano Onder,MD, PhD, Rosa Liperoti, MD, MPH, Manuel Soldato, MD, Iain Carpenter, MD,wKnight Steel, MD,z Roberto Bernabei, MD, and Francesco Landi, MD, PhD

RESULTS: One thousand one hundred eighty-four (36%) persons received a home care

program based on case management, and 2,108 (64%) received a traditional care approach (no case manager). During the 1-year follow-up, 81 of 1,184 clients (6.8%) in the case management group and 274 of 2,108 (13%) in the traditional care group were admitted to a nursing home (Po.001). After adjusting for potential confounders, the risk of nursing home admission was significantly lower for participants in the case management group than for those in a traditional care model (adjusted odds ratio50.56, 95% confidence interval50.43–0.63).

CONCLUSION: Home care services based on a case management approach reduce risk of

institutionalization and likely lower costs.

The Relational Nature of Case Manager Resource Allocation Decision Making:An Illustrated Case

Kimberly D. Fraser, RN, PhDCarole Estabrooks, RN, PhD

Marion Allen, RN, PhDVicki Strang, RN, PhD

To many people, decisions are choices between competing alternatives, but to home care case managers, their decisions are much more complex and are embedded within relationships in a multidimensional decision-making context.

Care Management and the Transition of Older Adults From a Skilled Nursing Facility Back Into the Community

Adam G. Golden, MD, MBA, Shanique Martin, BSW, Melanie da Silva, RN, Bernard A. Roos, MD

Care management interventions for more efficient and effective skilled nursing facility use must consider the determinants involved in the decisions to admit and maintain patients in skilled nursing facilities. As we await health care reform efforts that will address these barriers, opportunities already exist for care managers to improve the current postacute transition processes.