Unit 4: Case Management

(Screening Tools) *________________ Tools* are used by Case Managerto see/show what *may happen* in a given situation. Example: to show that clients who smoke cigarettes will likely have more upper respiratory infections.

*Predictive Tools*

- *Short Term* & *Long Term* goals - *Strategies to address* patient's *ongoing needs* - Improving *adherence* to *plan of care* (Input comes from: client, family, health care team, community care planners, payer) These are examples of how one might develop an *individualized C___________ P______________*

*Individualize Care Plan*

This is how the Case Manager facilitates communication and coordination of the entire healthcare team both in the care setting and with *outside agencies* aka *Multidisciplinary R___________*

*Multidisciplinary Rounds*

Someone who has been repeatedly hospitalized in a short period of time may require an inquiry by a case manager into the real necessary goals of current/future care. The goal with this referral would be to stop the cycle of ED visits or hospitalizations which is very expensive. This would require *H____________ U_______________ Referrals*

*High Utilization Referrals*

Someone with a diagnosis requiring expensive treatments (wound vac, trach, external defibs etc.) require knowing *what insurance is willing to pay* This would require a *H_______________-D_____________ Referral*

*High-Dollar Referral*

Follow up phone calls with a patient... example of conversation...

"did you get your meds without difficulty?" "how is everything going?" "I'm just checking on how you're doing" "Any questions or concerns?"

This is the Case Manager's collaborative effort with the *patient, family, caregivers, healthcare system* to plan course of treatment and outcomes aka C________________ P__________________

*Care Planning*

*Hospitals*, *Prisons*, *Military*, *Hospice*, *Long-Term Care Facilities*, *public insurance programs*, *private insurance companies* etc. These are all common *practice settings* where you will find...

*Case Manager*

This position requires *clinical expertise*, *critical thinking skills*, *diplomacy*, *adaptability*, *excellent organizational skills*, *knowledge of community resources*, the ability to *self direct*etc.

*Case Manager*

These are tools used by the case manager. They are *systematically developed statements* to *assist practitioner and patient decisions* about *appropriate health care* for *specific clinical circumstances* Most up to date courses of action for best practices

*Clinical Guidelines*

This is a *Multidisciplinary tool* used by the case manager for a *specific group of patients* w/ *predictable clinical course* in which the different *interventions* by the professionals involved in the patient care are *defined*, optimized and sequenced either *by hour (ED)*, *day (acute care)* or *visit (homecare)*

*Clinical Pathways*

These are *National standards of care* and *treatment processes* for *common conditions* which the case manager uses. Often-times presented as a *flow chart*. These processes are *proven* to *reduce complications* and *lead to better patient outcomes*. Compliance of these measures shows how often a hospital provides each recommended treatment for certain medical conditions.

*Core Measures*

Someone with a *new or specific diagnosis* must know what level of care they will need before they discharge. Example would be someone who got a tracheotomy. This would require a *D_____________ D___________ Referral*

*Diagnosis Driven Referral*

This is a checklist used by the case manager. *All needs are assessed* prior to discharge: Do they live alone? Do they need/use assistive devices? What medications will they need? Will they need in home care? What referrals will they require?

*Discharge Needs Assessment Tool*

(Screening Tools) *______________ Tools* can help the Case Manager *weigh the effectiveness* of an intervention. Example: diabetic education and the effect on the hemoglobin A1c.

*Evaluative Tools*

- *Does it work*? - Are *Costs* decreased for patient and payer? - *No readmission* or *reduced readmission* - Is *quality of care* and *overall health of patient* improved? These are ultimate *O_____________* of case management

*Outcomes*

- Discharge Needs Assessment Tools - Clinical Pathways - Core Measures - Clinical Guidelines These are all tools used in the __________ _____________ process

2. Clinical pathways: chart that tells you what needs to be done for discharging and case management. 4. Clinical guidelines: Latest/most up to date guidleines for best practice (i.e. Diabetes, heart failure etc.)

A Case manager evaluates their case management process by assessing patient Ad_____________, physician and community resource F____________-U_____. Biggest and easiest thing to do to follow up with a patient is to make a....

A Case manager evaluates their case management process by assessing patient *adherence*, physician and community resource *follow-up* Biggest and easiest thing to do to follow up with a patient is to make a.... PHONE CALL

The case manager is continually sticking up for clients and their families with the myriad of people and systems clients are thrust into with a new disease process or event. The case manager empowers clients to take charge of their condition, and helps them find ways to manage their disease or event to optimize their quality of life. This is how the Case Manager plays the role of patient/client ________________

Advocate.

*Comprehensive Assessments* *Care Planning* *Facilitating:* communication/coordination of the multidisciplinary team *Education* (treatment options, community resources, insurance benefits) *Empowerment of Clients* (problem solving by exploring options of care) *Encouraging use of resources* (maximizing quality of care) *Promoting Safe Transitions* *Promotes Self Advocacy/Self Determination* (Clarify POLST etc.) *Advocates For Clients* AND *Payer Source* (But client needs take priority) These are the major roles of a C______________ ______________

Case Manager

- Someone who's using *multiple providers* - *non-adherence to plan of care* - *increased severity* of condition - Care *not aligned with best practices* - *inappropriate services* or *level of care* - *repeat ED visits* - *Pt. got "fired" from PCP* These are all possible "areas for improvement* or problems/issues which need to be frequently assessed by the

Case Manager

Case management models are very *specific* to their facility. *Rounds* may be performed as walking rounds, or meeting room rounds etc. Case Managers may be assigned based on *U_______* or by *D____________* (aka *geography* or *disease*)

Case management models are very specific to their facility. Rounds may be performed as walking rounds, or meeting room rounds etc. Case Managers may be assigned based on *Unit* or by *Diagnosis* (aka geography or disease)

*Legal, cultural, spiritual or linguistic needs* *High risk patients* *High utilization referrals* *High dollar referrals* *Diagnoses driven referrals* These are all variables used to *identify* & *select* new...

Client Cases

Case management is not a profession, but a fluid and dynamic practice that involves many ________________ and continues to evolve.

Disciplines

One critical component to case management is teaching clients and their families about the new disease process, medication, or catastrophic event and rehabilitation. All of the health care information they have been given could be totally unfamiliar to them, and the case manager helps them to understand treatment options to help make informed decisions and locate community resources. This is how the Case Manager plays the role of ________________

Educator.

The case manager works closely with the client and family to make mutually acceptable goals and the methods used to achieve such goals. This aspect is crucial in helping the client to achieve optimal outcomes and contain costs for all. This is how the Case Manager plays the role of ____________________

Planner/coordinator

The case manager must have excellent communication skills to manage all coordination for the client with all health team members. This element is critical in helping avoid fragmentation of services for the client. This is how the Case Manager plays the role of ________________

Facilitator/negotiator

(Screening Tools) This is a lengthy evaluation tool that demonstrates clients' own perception of their health status, and the results are used to predict whether clients have an increased risk of requiring additional care. They are used in several disciplines, and are *one of the first assessment tools that a case manager uses* in beginning a client's case.

Health Risk Assessment (HRA)

Are all cases eventually terminated by the case manager?

No Not every case is terminated; for example, the ongoing management of a client's chronic disease. For this standard to be met, the case manager has to document the identification of reasons for terminating management of a client, such as reaching mutually agreed-upon goals, client refusal, or client death.

Medi__________ will pay for follow up phone calls

Medi*care*

Once *all goals have been met*, or the *client changes their health setting*, or they *move*, or they *refuse care*, or become *non-adherent* Then the case manager can commence with he *T________________ Case Management Process*

Once all goals have been met, or the client changes their health setting, or they move, or they refuse care, or become non-adherent Then the case manager can commence with he *Termination Case Management Process*

(Screening Tools) This is a 13-item survey that assesses clients' knowledge, skill, and confidence in their ability for self-care. Scores can be used to predict health outcomes, including ED usage and medication adherence compliance.

Patient Activation Measure (PAM)

The clients who are identified as *high risk* by *Predictive Modeling* (PM) are those that the case manager will focus on, and may be designated as "high-_________."

Touch

Which are common means that *insurers and Case Managers* use to *identify potential patients* for case management *services*? Screening for Catastrophic/New *D____________*, Sentinal procedures, *H_______-Claims Cost* and

Screening for Catastrophic/New *Diagnoses*, Sentinal procedures, *High-Claims Cost* and

(Screening Tools) This screening tool is a multipurpose health survey with 36 questions that has proven to be both reliable and valid. It has functional health and mental health measures, and is generic and not disease specific.

The 36-item Short-Form Survey (SF-36)

Many discharge delay come down to E_______ issues

ethical issues