Case Management Case Management ProcessesProcesses

Case Management Case Management ProcessesProcesses

Assessment

Functions of Case Management

Direct Outcomes ofCase 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 AccountabilitySpectrum of Accountability

Stages Of The Case Management Process:

A. Case SelectionB. Assessment or Problem IdentificationC. Development and Coordination of the Case

PlanD. Implementation of the PlanE. Evaluation and Follow-UpF. Continuous Monitoring, Reassessing, Re-

evaluation

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.

A. Case Selection

4. Determines the need for case managementa. 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 identifiediii. If readmission is not a concerniv. There are no financial barriers present

d. Case management may be necessary when there arei. Complex medical issues or comorbiditiesii. Complex discharge needsiii. Complex social issues

A. Case Selection

7. Establishing selection criteriaa. 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 disabilityii. Age over 65 yearsiii. Readmission within 15 days or Repeated admissions to acute careiv. Overdose or Alcohol and drug abusev. Chronic mental illness or Alzheimer's dementiavi. Noncompliance or Uncooperative, or aggressive behaviorvii. Suspected child or elder abuse and neglectviii. Homelessness or Poor living environmentix. Residence in rural community with limited or nonexitent servicesx. Limited financial resources or No or inadequate health insurancexi. Single parentxii. Dependent in activities of daily living

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)Patientb)Family physicianc) Office and hospital medical recordsd)Ancillary staffe)Familyf) Employer

B. Assessment or Problem Identification

4. Patient data to be collecteda)Patient history and demographicsb)Current medical statusc) Nutritional statusd)Medication assessmente)Financial assessmentf) Functional assessmentg)Environmental factorsh)Psychosocial assessmenti) Cultural and religious diversity

C. Development and Coordination of the Case Plan

1.Establishing goals2.Prioritizing needs and goals3.Service planning and resource allocation

D. Implementation of the Plan

1. Case managers within a facility (internal)a)Before dischargeb)The day of discharge

2. Case managers outside of the facility (external)a) Initial checksb)Intermediate checksc) Case closure

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.

E. Evaluation and Follow-Up

1. Depends on the type of case management employed

2. Case evaluation3. Case management outcomes

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 status3. Changes in social stability of the patient4. Quality of care5. Changes in functional capacity and mobility6. Evolving educational needs7. Termination of case management services

Care Management Processes in Physician Organizations (N = 1,040)

Process Diabetes Asthma CHF

1. Case management 39.7 39.7 43.4

2. Feedback to physicians

24.1 24.1 30.5

3. Disease registries 31.2 31.2 34.8

4. Clinical guidelines with reminders

33.9 33.9 27.7

Practices using all 4 12.7 7.6% 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.