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39 Cards in this Set
- Front
- Back
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National Transitions of Care Coalition (NTOCC)
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recognized the convoluted manner in which patients are often transitioned in the civilian sector, causing undue burdens and delays in treatment and management interventions
Organizations representing physicians, pharmacists, nurses, case managers, social workers and other health care professionals joined together to identify and initiate policy, services, and criteria that may improve transitions of care for patients across the care continuum. More than 25 stakeholder organizations across the US convened in 2007 and formed to establish consistent criteria when transitioning patients from one level of service to another in the US health care system |
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Acute care hospitals in the US represent
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the largest segment of health care settings
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The care continuum defines
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all levels of health care interventions and services currently offered in the US health care system to treat and manage patients from birth to death, as well as wellness-based interventions intended to keep the individual at an optimal state of wellness.
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Hospitals and related physician expenditures traditionally account
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account for the majority of health care spending
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Before the advent of managed care in the mid 1990s, it was relatively common for individuals to be treated
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in the hospital whether or not they really needed in-patient care.
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Post-Acute Care
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occurs following an episode of care in the acute care setting (rehab facility as example)
case manager or discharge planner is responsible to ensure that the transfer is performed in a safe manner; it is important that the patient is medically stable for transfer and agrees to the plan of care physician must be willing to follow the patient in the new setting, and a report is given to the receiving facility concerning the current status of the patient Once information is obtained, and appropriate paperwork is signed, a copy of the entire medical record should accompany the patient so that the receiving facility has information on what occurred in the acute care setting case manager or the discharge planner should be available for any questions that arise as a result of the transfer |
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due to the advent of managed care, for admission and treatment
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there are several acuity levels that must be met before a patient can be admitted to a hospital
The treating physician must ensure that the patient meets specific criteria that support the need for admission Managed care settings, as well as other payer systems, require that utilization procedures be implemented in acute care settings to ensure that patients admitted meet specific criteria, and that those confined to the hospital continue to meet the criteria for acute care |
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acute care setting
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The purpose is to diagnose and treat those who are too sick to have procedures and treatments performed in alternative settings
Documentation which includes medical necessity for testing and procedures is needed by the managed care organization (MCO) from the acute care facility to evaluate whether the care given meets the required criteria case manager who works acute care must ensure that the procedures planned are performed in a timely manner and results are obtained, interpreted, addressed promptly to allow the health care team to determine the future plan of care obtain accreditation, such as Joint Accreditation, to show the community and the payer(s) that they meet standards set by organizations. These accrediting organizations in turn look to case management departments to show that care is coordinated through each delivery segment of the acute care setting. |
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Payer organizations send external case managers into the acute care setting to control or
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direct resources
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Acute care case managers
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are charged with proactively identifying patients who will not meet specific criteria or who have social/financial problems that cause them to have extended or frequent stays
Once obstacles are identified, they can begin to address the needs of the patient and/or family by implementing an individualized plan of care |
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One of the major stakeholders in hospital-based case management is the Centers for Medicare and Medicaid (CMS), due largely
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to the fact that CMS is a major payer for services in the acute care setting.
NOTE: As such, hospital-based case managers need to be appraised of the most current performance criteria required in order to transition patients through the acute care setting efficiently and effectively. |
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Skilled nursing facilities
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are specialty centers that care for patients who have long-term needs and are unable to care for themselves
Many who reside in these centers are elderly, but skilled nursing facilities can also focus on the child who has severe disabilities goal of these centers is to maintain the maximum health status for the residents and care for them in a humane and passionate manner Case managers who work there should ensure that current advance directives are in place, so that, if a patient must be transferred to an acute care setting, this information can be communicated are also used by many managed care settings for those patients who may require rehabilitation but do not currently meet the requirements for acute rehabilitation at the time transfer is deemed medically necessary Patients may be directly admitted from the home or an emergency department when the patient has needs that do not meet criteria for acute care but also are not stable enough to go home |
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Rehabilitation
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are sometimes synonymous with skilled nursing facilities, but there are also many specialty, stand-alone rehabilitation centers throughout the US which specialize in intense inpatient and outpatient rehabilitation
The patient can receive care following an injury or an illness that diminishes their ability to care for themselves, including complications or deficits, which hinder activities of daily living (ADLs). have specialized staff who can address the physical, functional, and psychological areas affected by a catastrophic injury or illness elect to meet strict criteria set by the Commission on Accreditation of Rehabilitation Facilities (CARF), which ensures that the facility has the staff and the expertise to meet the services provided can be performed in an inpatient setting, a transitional setting, or in the outpatient setting Each setting has specific criteria, and the rehab team, led by a physiatrist, will usually make the determination as to when the patient is ready to move from one setting to another case manager who works in the rehabilitation setting is considered a specialist in rehabilitation case management |
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Home Health Care (regarding the CM responsibilities)
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Case managers and discharge planners must be cautious when discharging a patient to home, to ensure that the family is prepared to safely handle the needs of the patient
key to understanding the needs of the patient and family is to ensure that comprehensive assessment using an interdisciplinary team identifies all needs required to transition the patient from the inpatient setting to the home setting Proactive, collaborative discharge planning will assist in determining the needs of the patient and in finding the correct setting for the patient, once medically stable Partnering with home care organizations to meet various needs of patients helps the case manager or discharge planner ensure that the plan of care is safe teaching is a key component when preparing the patient and family for the return home, as is helping the family to understand and to perform the care needed case manager must advocate with the payer and, many times, with members of the patient's family, to ensure that respite care is incorporated into the treatment plan to prevent burnout of the caregiver In long-term cases, it is particularly important that attention is paid to the caregiver, since this role is often overlooked |
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Durable medical equipment (DME) companies
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are organizations that supply equipment and other supplies that a patient will need when care is provided in the home
provide what is called a "one-stop-shop." Some DME companies supply only medication and nursing care, while others simply specialize in equipment and supplies The type of company the case manager uses will depend largely on the payer source and the specific needs of the patient/family. The case manager or discharge planner should verify whether the patient has insurance or how services/products are going to be financed, prior to coordinating services. If the patient or family cannot afford equipment, community resources can be investigated. It is important that the patient and/or family understand how to use any equipment or supplies that are delivered to the home. Education can be provided directly from the DME provider, or by a specialist/consultant. |
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Hospice
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is used to assist the patient and the family when a chronic condition or an injury is likely to result in death in the "near" future, and the patient does not want aggressive treatment that will prolong life
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Advance directives
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give individuals a way to communicate in advance about how they want to be treated when death is imminent
must be recognized and respected by the health care team Case managers are required to ask about the wishes of those who are terminally or chronically ill and ensure that those wishes are respected. |
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The current focus of hospice has shifted from looking at the patient who is assessed as terminally ill, to working
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earlier with patients who have progressive chronic illness, such as COPD or cancer, to address issues concerning the end of life
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Long-Term Care (geriatric)
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The focus is on specific populations that require professional or personal services on a recurring or continuous basis due to aging or the presence of a chronic or permanent physical or mental impairment
Populations that fall under this category include the elderly, because of their age and inability to function; adults who suffer from chronic illness or catastrophic injuries that render them dependent; and children who require long-term care because of devastating injuries, illnesses, or congenital defects Payment for services provided by the geriatric case manager is usually made on a fee-for-service basis to whomever contracts the service (ie paying bills, shopping, housecleaning) Many companies that specialize in long-term care insurance are now employing geriatric case managers to assist with care once a policy is activated. |
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Long-Term Care (children with chronic conditions)
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have birth and genetic anomalies, complications from birth that have left them disabled and dependent, and various accidents that have caused permanent damage, such as near-drowning and brain and spinal cord injuries
Case managers who work with this population, either in private practice or through a government agency such as Medicaid or Children's Medical Services, are most successful when relationships are formed among families, physicians, and nurse care coordinators, since the needs of these children are so diverse. |
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Long-Term Care
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Patients who are over 21 years of age and under the age of 65 with long-term needs often are covered by private health care insurance
payer-based case manager usually addresses the needs of this population if they have private insurance Other sources of coverage are found through either Medicaid or Medicare injury or illness results from an accident or work-related injury, coverage will be provided by a workers' compensation carrier goal for case managers who work with this population is to strive to ensure that each patient reaches maximum potential, and to educate those with a chronic illness or injury on how to navigate the health care system |
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Long term care injury as result of an accident:
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a legal settlement may have set up a trust that provides money for long-term care needs or medical care not covered by insurance
In such cases, to structure payments, a life-care plan may be needed to outline future needs over a lifetime, so that funds can be conserved and used efficiently. In cases such as this, a trust officer or bank may be responsible for dispensing funds for long-term care An independent case manager or the workers' compensation case manager may assist with management of care for this population If the case manager is not involved, the family or primary caregiver will assume this role. |
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A proactive approach to assessment, management, and ongoing care and support for those who require long-term care is one way
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that problems can be recognized early, treatment initiated, and costs controlled
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Assisted living
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is another form of long-term care which provides a greater level of independence that many seniors are moving toward when they can no longer function safely or conveniently in their own homes
An assisted living facility allows a person to live in his/her own apartment or room, and then join the community for activities and meals. This type of setting allows the elderly person to remain relatively independent while allowing for assistance to be given to ensure safety and proper nutrition. Many churches or community agencies have set up assisted living programs for those who are catastrophically ill or disabled due to mental or physical conditions. Safety and proactive management to ensure adherence to treatment are important in this population. Assisted living programs can also provide respite care for families who have elderly or disabled persons. These programs allow caregivers to continue to work or have a break from the daily routine while the disabled person is being cared for in a safe environment that can stimulate awareness. |
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Private duty nursing
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is implemented in situations when the patient requires one-on-one care
because of the nursing shortage, many families are using private duty nurses to help care for their family members while in the hospital insurance companies do not typically compensate for the cost of private duty nursing, since it is a choice of the family is also effective for children and adults who are catastrophically impaired and require around-the-clock nursing care Financing this type of care is very expensive and typically not covered under traditional insurance Sometimes, nurses are "hired" and work privately to care for a person who requires private duty nursing. In this case, the family is the employer and is responsible to pay the individual nurse, including covering them for such things as workers' compensation and income taxes. In the case of legal settlements, structured payments may be set up after a settlement is made to pay for private duty nursing care |
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Case management of Private duty nursing
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Independent case managers can work with the family in need of private duty care to find an agency that can provide this type of service
The case manager may be able to negotiate a special rate, since the care is ongoing and long-term. The case manager who assists with this type of coordination should encourage the family to seek expert advice about what their responsibility is when undertaking this type of project, to follow the various federal and state requirements that apply to employment. |
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Common Case Management Settings
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• Private Insurance, Workers' Comp, Disability, Liability, Casualty, Auto Accident and Health
• Managed Care Organizations • Independent CM • Provider Agencies • Mental Health Agencies • Home Health Agencies • Ambulatory Facilities • Disease Management Companies • Hospice • Hospitals, Integrated • Delivery Systems • Sub-Acute Care • Skilled Nursing Facilities (SNF) • Rehabilitation Facilities and Clinics • Corporations • Public Insurance, Military, Prisons, Government • Geriatric Practices • Physician Practice Groups |
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Internal Case Manager
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This term is often used for a case manager who functions within a payer-based system.
Examples: Case manager working for a managed care organization (insurance company); a case manager working for a third party administrator (TPA); a case manager working for a reinsurance carrier (excess lines); a case manager working for a self-insured employer. |
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External Case Manager
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This term is often used for a case manager who works within a payer-based system, but maintains his/her caseload from outside of the payer's physical location.
Examples: Field case manager working for a workers' compensation carrier; an on-site case manager working for a health maintenance organization (HMO) or long-term care (LTC) insurance company. |
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Independent Case Manager
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This term is often used for a case manager who contracts services with various payers, providers, or even consumers as an independent contractor.
Independent case managers can be paid on a fee-for-service or capitated basis, or through negotiated arrangements. Independent case managers are responsible for carrying their own malpractice insurance and operate within the scope of an independent business owner. |
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Provider-Based Case Manager
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used for a case manager who works in the provider setting.
This is the broadest category of case managers, which can include, but is not be limited to: physician groups and independent practice associations (IPAs); hospitals; rehabilitation facilities; outpatient surgical centers; home health care agencies; daycare agencies; social service organizations; behavioral health settings; federal and state correctional facilities, etc. |
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Community-Based Case Manager
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This term is often used for a case manager who works within a local state health department or non-profit agency.
This case manager will typically work with low-income populations who are under-insured or on Medicare or Medicaid. Examples: State health departments; community-based group homes for drug addiction; state or county funded hospitals and clinics which provide indigent care. |
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Patient & Family Advocate
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With education and support, the client will become empowered and self-reliant. Thus, advocacy is an ongoing role of the case manager and must involve critical thinking and objectivity.
The case manager, as a patient/client advocate, has a responsibility to discuss alternative options available to the client, even if those options are outside the benefit plan or in conflict with the case manager's belief system. The interest of the client is represented by advocacy for the necessary funding, the best treatment alternative, timeliness, coordination of health services, and frequent re-evaluation of goals and progress. sometimes places the case manager in a difficult position with the payer or other members of the health care team. However, advocacy must remain in the vanguard of the case management process. is one of the key roles that distinguish case management from other health care management processes, such as utilization management. |
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Empowering the Patient/Family
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are essential in case management, particularly in the wake of limited financial resources for necessary services.
allows the patient to achieve greater independence through self-determination |
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Empowering the Patient/Family
As case managers strive to empower the patient, it may be helpful to keep in mind the following tips: |
1. When the help-giver is positive and proactive, the help is most useful.
2. If the help-giver offers help rather than waits for it to be requested, help is more likely to be favorably received. 3. When the help-giver allows the focus of decision making to rest clearly with the help-seeker, the help is more effective. 4. If the aid and assistance provided by the help-giver are normative and do not infer deviance or undue variations, the help is more effective. 5. When the aid and assistance provided by the help-giver are harmonious with consideration of the help-seeker's problem or need, the help is maximally effective. 6. When the costs of seeking and accepting help do not outweigh the benefits, the help is more likely to be favorably received. 7. If the help can be reciprocated and the possibility of "repaying" the help-giver is sanctioned and approved but not expected, the help is more likely to be favorably received. 8. If the help-seeker experiences immediate success in solving a problem or meeting a client's need, the help is more likely to be deemed beneficial. 9. If the help-giver promotes the family's use of natural support networks and neither replaces nor supplants them with professional networks, the help is likely to be more effective. 10. When the help-giver conveys a sense of cooperation and joint responsibility (partnership) for meeting needs and solving problems, the help is more likely to promote positive functioning. 11. If the help-seeker perceives improvement and sees him or herself as the responsible agent for producing a change, the help is most likely to be beneficial. |
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Family-centered case management
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is one way the case manager can work toward empowering the patient and the family/significant other/caregiver in the family unit
is based on recognizing that the family is the most important social institution, playing the premier role in the case and nurturing of its members has evolved because families have stated—and policy-makers and professional helpers have believed them and responded appropriately—that they need assistance with managing care is based on recognition of family strengths and a commitment to reinforce those strengths. is also intended to support families in fulfilling their enormous commitment to the nurturing and well-being of their members |
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education
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to be effective, it should be imparted continuously, reinforced at every opportunity, and be non-judgmental and objective
starts with how the message is delivered and requires awareness of the other person's body language, facial expressions, and emotions Sensitivity to the needs of the patient, family, and/or caregivers is crucial to actively engage them in the care process. Therefore, listening is as equally important in education as speaking clinical case managers from all practice settings agree that education of the patient and family or other caregiver is an essential component of the case manager's clinical practice |
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Team Communicator
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the case manager strives to: achieve the goals of a patient/family advocate; encourage coordinated care among specialty physicians; get team members on the same page by focusing on process and outcomes; promote patient/family self-empowerment; understand how to effectively use the payer system; and acquire knowledge of community and other resources to benefit the patient/family.
critical for the case manager to communicate issues regarding a patient's care plan with physicians, staff nurses, social workers, therapists, and other health related professionals All aspects of the case management process, as identified by the CCMC, involve effective communication: assessing, planning, implementing, coordinating, monitoring and evaluating the care In the American Nurses Credential Centers' Nursing Case Management Model, communication is not an assumed role. Rather, it is clearly identified as one of the processes of case management under the term "interaction". |
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Team Communicator
Effective CM |
An effective case manager will be assertive -- not aggressive -- and will utilize diplomatic and discreet communication and understand the nature and benefits of compromise when necessary.
However, with the increased diversity in a growing multicultural society, the greatest barrier to effective communication may not be uncooperative team members, but language barriers. The case manager is challenged to ensure that the client whose primary language is not his or her own understands all of the medical terminology and colloquialisms used today. The case manager must not only ensure access to a translator but obtain access to a health care provider who speaks the patient's primary language, if possible. |
