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1

The Companion Module embodies principles

of adult learning through case-based learning

2

The most effective, consistent process of case management is one that promotes

quality, cost-effective care at the most appropriate time, in the least restrictive environment.

is a collaborative process whereby the case manager serves as a catalyst for quality, cost-effective, and timely health care delivery by enhancing available resources and services while reducing fragmentation

3

The Commission for Case Manager Certification (CCMC) identified 9 major phases in the case management process through which case managers move to provide care to their clients.

1) Screening 2) Assessing 3) Stratifying Risk 4) Planning 5) Implementing (care coordination) 6) Following Up 7) Transitioning (transitional care) 8) Communicating Post-Transition 9) Evaluating.

4

Who should be offered the services of a case manager, regardless of the ability to pay for those services?

All individuals, especially those suffering from catastrophic, high-risk, multiple, or complex costly diagnoses or injuries, including those that are resource intensive, and those suffering from chronic conditions that are complicated by traumatic events,those with complex psychosocial or environmental factors (family obligations) that impact the ability to achieve health or maintain function, and those that require extensive monitoring and coordination of needs.

5

The following bulleted points offer a theoretical framework about case management:

• Holistic and client-centered care
• Mutually agreed-upon goals
• Cost effectiveness
• Working collaboratively with health care providers
• Enhancing client's safety and well-being
• Optimizing outcomes

6

Care coordination in the 2010

through case management has finally been recognized as a value-added service to promote patient-centered care and reduce costs.

is mandated in the Centers for Medicare and Medicaid (CMS) guidelines;

receives repeated recognition in health care reform

is a component of medication therapy management (MTM) programs;

is grounded in emerging models of Accountable Care Organizations and Medical Home.

7

Case management in the 2000s

Case management evolved into a care coordination model, with particular emphasis and focus on advanced issues that include wellness, preventive education, resource management, disease management, consumer advocacy, and measurable outcomes to achieve quality, cost effectiveness and basic access to care.

As the health care system becomes more convoluted and complex, points of entry into case management are becoming more varied, with direct consumer purchases of case management services increasing.

Case managers are in hospitals, home health agencies, infusion care companies, rehabilitation agencies and the military. They work in managed care organizations (MCOs) for third-party administrators (TPAs), or major insurance carriers.

8

Case management in the 1990s

Managed care quickly accelerated as a means to control spiraling health care costs. From 1992-1993 general memberships under managed care plans were, for the first time, greater than the memberships enrolled in traditional indemnity health plans.

Case management became integrated, both intra- and inter-systematically, as a result of a paradigm shift in the delivery of health care in the US.

This massive change in the shift of risk from insurance companies to providers changed the way case management obtained cases and began to create an advanced case management industry.

9

Case management in the 1980s

Case management became well documented in the group health setting with several different disciplines entering newly emerging utilization management and care coordination models.

Companies like Intracorp became well known for their creative case management models and their ability to document clinical and economic outcomes on behalf of their clients.

In the 1980s, case management also expanded from a primarily community-based practice to a hospital-based practice.

10

Case management in the 1900s

During the turn of the 20th century, public health nurses and social workers coordinated services through the public sector.

Today's case managers share concepts of both community-based nursing and public health nursing of the early 1900s, when pioneer public-health nurse Lillian Wald redefined the role of the home visiting nurse to include holistic care and set the stage for public health nurses of the post-war eras.

Despite Wald's well-documented case management activities and her founding of the Visiting Nurse Association (VNA), the literature often defines the roots of case management as being in the post-World War II era in America.9

11

Case management in the 1950s

After World War II, insurance companies began to employ nurses and social workers to assist with coordinating the care of soldiers returning from the war who suffered complex injuries requiring multi-disciplinary intervention.

Insurance companies also used nurses to assist employees with work-related injuries to expedite the return-to-work transition.

12

Case management in the 1960s

The evolution of formalized case management began with Medicare and social services demonstration projects.

Social workers were usually employed to coordinate services for clients in low-income groups, the mentally ill, or the frail and elderly.

In fact, many of the fundamental principles used in case management today developed their roots from the excellent processes used by social workers who had to employ creative resource management in the midst of limited funding and post-acute services.

13

Case management in the 1970s

The workers' compensation system adopted the case management process as a means to manage indemnity and medical care costs proactively, from onset of injury to successful return to work.

Rehabilitation case management took hold as a common component of medical coordination, and nurses were often used to negotiate the complicated regimen of acute care and rehabilitation required for catastrophically injured workers.

14

An example of how the social work model brings to light the case management process can be gleaned from a demonstration project that was known

as Chicago's Hull House

BACKGROUND: Chicago's Hull House was founded in 1889 to offer a variety of programs for the immigrant populations. The major contribution that came from this program, which remains significant to the practice of case management today, is the recognition of the worth of individualized treatment and the need to assist patients toward self-support and self-sufficiency. The program established that there was a need for a trained staff as well as the systematic collection of data in order for effective outcomes to be achieved.

15

The case management model traces its roots to Lillian Wald,

Lillian Wald, a leader in public health nursing, who worked in New York City in the early 1900s

BACKGROUND: Wald's accomplishments set the principles on which today's case managers have been able to build. Specifically, Wald showed the importance of early identification of those who are at risk for developing complications from illnesses and injuries; the need for proactive education for the patient and their families; and the importance of viewing the patient and the family holistically in order to improve quality of life and contain health care costs.

16

Wald organized the

Settlement House to care for the elderly, pregnant, and disabled people of New York City's lower East Side.

BACKGROUND: Wald and the nurses visited those in need in their homes to educate about germs, transmission of disease, and the importance of good personal hygiene. They provided preventive, acute, and long-term health care to all with whom they worked. The programs were so successful that they expanded to include assistance with housing, employment, and education for exceptional and mentally challenged children.

17

Other efforts led by Wald, which remain a major focus for case managers specializing in the occupational health setting, were

those to improve the health of employees in the workplace

BACKGROUND: Wald challenged major industries to provide health inspections of the workplace to protect workers from injuries. She was able to persuade corporation executives that protecting the health of their employees made good business sense. She encouraged them to implement preventive medicine and to have nursing or medical professionals at the work site at all times. Wald's philosophy remains a cornerstone to the current practice of occupational health case management.

18

According to the NASW, social work case management is a

method of providing services whereby a professional social worker assesses the needs of the client and the client's family, when appropriate

19

The SWCM:

arranges, coordinates, monitors, evaluates, and advocates for a package of multiple services to meet the specific client's complex needs.

is the primary provider of social work case management.

addresses the individual client's biopsychosocial status as well as the state of the social system in which case management operates.

is both micro and macro in nature in that services provided under this practice may be located in a single agency or may be spread across numerous agencies or organizations.

"Clients" may refer to individuals, families, groups, or communities

20

The National Association of Social Workers (NASW) implemented a social worker case management certification process in 2000 that allows

that allows social workers with expertise in case management functions to achieve recognized certification as a certified social work case manager (C-SWCM) or as a certified advanced social work case manager (C-ASWCM).

21

The Commission for Case Manager Certification (CCMC) defines case management as

a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's (consumers, patients, or other recipients of case management services) health and human service needs

characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes

22

In its case management certification process, the American Nurses Credentialing Center (ANCC)5 defines nursing case management as

an active and systematic collaborative approach to providing and coordinating health care services to a defined population.

a participative process to identify and facilitate options and services for meeting individuals' health needs, while decreasing care fragmentation and care duplication and enhancing care quality and cost-effective clinical outcomes.

23

Revised CMSA Definition of case management:

is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality cost-effective outcomes.

24

The updated CMSA CM definition of revised version supports a

multi-disciplinary role of case management, rather than focusing on case management as a function of nursing or social work

25

Original CMSA Definition of case management

is a collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual's health care needs through communication and available resources to promote cost-effective outcomes

26

The Institute of Medicine (IOM) report, Crossing the Quality Chasm, called for a health care system that could achieve six dimensions of quality: health care should be

(1) safe, (2) effective, (3) patient-centered, (4) timely, (5) efficient, and (6) equitable.

27

case management

process exists to ensure that appropriate, quality care is provided for individuals who are at risk, in a timely and cost-effective manner

services are individualized, holistic, and meant to enhance self-care through the continuum of care

is a dynamic and fluid process that spans the continuum of care regardless of the practice setting, payer, or environment. It transcends government programs funded through the Centers for Medicare and Medicaid and private sector programs

28

Managed care has decreased the need for price negotiations due to

provider contracts that are set up in advance

29

the case manager

is viewed as the negotiator of care rather than the negotiator of costs

looks at the entire process, rather than only at the narrow focus on costs

has the obligation to ensure that the services and products put into place are medically necessary, priced appropriately, and delivered with high quality service

effective negotiation skills resolve conflicts that may arise.

must have the ability to interpret complex, detailed clinical and financial information to disseminate that information to individuals who need to know

is able to identify problems, investigate solutions, and work to ensure that a timely resolution occurs to maintain continuity of care. As professionals at the center of the team, case managers

must be able to take a vast amount of information and summarize it without distortion and without insinuating personal judgment

must have concise questions that allow professionals to understand what is being asked, and to provide information for specific questions

30

Many case managers adhere to

definitions and accompanying standards of practice in accordance with their licensing and certification requirements

31

In cases of sudden catastrophic illness or injury

early referral to case management services is essential to ensure that the patient is admitted to the appropriate facility that will meet his/her medical needs

32

For those who suffer from chronic illness or progressive disease

the need for case management services is determined by how the patient and the family are handling their specific challenges

33

The 2002 revision of the CMSA Standards of Practice included a section on Performance Indicators in case management. These were listed as follows:

• Quality of Care
• Qualification
• Collaboration
• Legal
• Ethical
• Confidentiality
• Advocacy
• Resource Management
• Cultural Competence
• Research Utilization

34

Standards of Care in case management, as identified by the 2010 CMSA Standards of Practice for Case Managers, lists the following case management processes:

• Client Identification and Selection
• Assessment and Problem/Opportunity Identification
• Development of the Case Management Plan
• Implementation and Coordination of Care Activities (Monitoring)
• Evaluation of the Case Management Plan and Follow-up (Outcomes)
• Termination of the Case Management Process

35

The essential components of case management as defined by the 2002 CMSA Standards of Practice for Case Managers

are assessment, planning, facilitation and advocacy.

36

The 2009 Standards identify evolving changes, including a broad-reaching study conducted by the Commission for Case Manager Certification (CCMC) and published in 2006, which further defined these essential components as

assessment, planning, implementation, coordination, monitoring, evaluation, outcomes, and a general category, meant to include activities performed across practice and process such as maintaining privacy, confidentiality and safety, advocacy, and adherence to ethical, legal and accreditation/regulatory standards

37

A fundamental and meaningful way to explore how the process of case management is engaged by the care coordination team is to look at the

Case Management Society of America Standards of Practice for Case Management

NOTE: The 2010 CMSA Standards of Practice (the most current version) represent the most rigorous compilation of evidence-based case management standards of care and standards of performance published within the current civilian health care industry.

38

The American Nurses Credentialing Center (ANCC) also outlines "knowledge domains" in which a nurse must demonstrate proficiency in order to become certified as a nurse case manager. The ANCC refers to these as "Domains of Practice", which have been updated for the Case Management Nursing Board Certification, effective May 2012. The five domains encompass a broader reach of nursing case management practice that mirrors the evolving role of nurse case managers within new health policy and care coordination models. Domains of Practice include:

1) Clinical Case Management Practice; 2) Resource Management; 3) Quality Management; 4) Legal and Ethical Considerations; and 5) Education.

39

According to the CCMC, case managers should be able to demonstrate competency in applying the eight Essential Activities to the seven Knowledge Domains of Case Management. Identified by the CCMC in its 2011 publication, The Case Management Body of Knowledge (CMBOK), the seven Knowledge Domains are:

1. Case Management Concepts
2. Principles of Practice
3. Healthcare Management and Delivery
4. Healthcare Reimbursement
5. Psychosocial Aspects of Care
6. Rehabilitation
7. Professional Development and Advancement

40

Among the Essential Activities of case management, the "General" element may be the most difficult to define, but actually includes some of the most fundamental elements of case management (examples):

eg, maintaining client's privacy, confidentiality and safety; advocacy; adherence to ethical, legal and accreditation and regulatory standards

41

Performance improvement

is a process that allows health care organizations to determine how their services are meeting the needs and expectations of those who use services

formal process implemented in the early 2000s in the US health care delivery model

critically evaluates clinical, financial, and utilization data, information is obtained that allows performance measurements to be implemented throughout the continuum of care

goal is to ensure that the systems in place are able to meet the patient's needs and expectations

42

While the case manager is responsible for initiating the interventions and monitoring the plan's effectiveness, evaluation is incomplete unless a formal process to document and analyze the data is initiated. It is in this process —outcomes measurement— that the true value and

return-on-investment (ROI) of case management can be realized

NOTE: The process of measuring the interventions to determine the outcomes of case management involvement includes measuring clinical, financial, variance, quality of care, quality of life, health care, and client satisfaction outcomes.

43

Evaluation

is the process of reviewing the overall plan of care to determine whether desired outcomes and goals as set in the initial plan of care were achieved

like monitoring, may also lead to modifications or changes in the ongoing care plan

also includes the documentation of outcomes, which must clearly indicate the case manager's direct role in order to be claimed by the case manager

is a continuous process

includes return on investment (ROI); performing cost and benefit analyses; measuring quality of life; identifying outcomes specifically related to case management interventions; impact of case management interventions on overall population health; effectiveness of the case management program; determining if specific patient/family goals were met; and determining provider and member satisfaction

44

Monitoring

makes sure modifications to the plan are identified and implemented

is paramount to the ongoing appropriateness of the case management plan

45

Coordination

is the process of organizing, obtaining, integrating, and updating, if necessary, the resources required to achieve the case management plan

also includes being the catalyst for the effectiveness of the plan as carried out by the treatment team ("facilitation")

continues to promote communication between all team members, the patient, and the family/significant other/caregiver

will focus on the best plan, will reduce fragmentation, will enhance the treatment plan, and will ensure a good outcome

may need to use conflict resolutions and consensus building skills to reconcile differing points of views and to assure the patient/family's wishes are understood

activities hope to avoid service duplication, ensure timely and appropriate provision of services, identify care delivery barriers and explore alternatives, match patient needs with available resources, optimize health care resources, and organize and manage the care plan activities

46

Implementation

includes responsibility to uphold patient confidentiality, interests, and other client-focused components crucial to appropriate and ethical plan implementation

involves carrying out interventions that will lead to completing the stated plan goals

includes advocating for the patient/family, communicating with all members of the health care team, documenting treatment progress, modifying the plan as appropriate, educating the patient and family education, and organizing and optimizing patient/client services

arranges for services to be provided to the patient via referrals or direct interaction and communication with other health care organizations and providers

47

planning

goal is to develop an appropriate and fiscally responsible care plan that enhances quality, access, and cost-effective outcomes

includes the patient as the main decision maker and goal setter in the care plan

Key elements include: individualization for the client, with goals that are action-oriented and time- and goal-specific; identifying an immediate patient support system; advocating for the client/family as needed; and identifying actual/potential resources

Timelines and frequencies are created regarding specific interventions.

Specific goals are integral, but because the plan of care is a dynamic process, modification to the goals may be necessary to adapt to changes occurring over time and through various settings

secondary or contingency plan to the proposed treatment plan is also essential to consider

48

Assessment

is gathering all pertinent data and obtaining information from the initial interview with the people involved in the case

information is evaluated objectively and critically in order to identify and clarify issues related to the case and to determine realistic goals and objectives as well as alternatives to the present situation

Pertinent data not only includes medical and psychosocial information but should also include information regarding the client's cultural influences and belief or value system.

NOTE: Common assessment tools are Health Risk Assessments (HRA) which allow the case manager to gather a holistic viewpoint of the patient's current disease process as well as risk factors that can impact the current and future disease process.

49

The eight Essential Activities of Case Management, according to the CCMC, are:

• Assessment
• Planning
• Implementation
• Coordination
• Monitoring
• Evaluation
• Outcomes
• General

NOTE: The General category is intended to capture the cornerstones of moral, ethical and legal case management practice, including patient confidentiality, safety, advocacy, and adherence, as well as the case manager's obligation to general accreditation and regulatory standards.

50

Based on the results of the 2006 Tahan and Huber study, the CCMC increased the number of Essential Activities required of the case manager from six

to eight

51

Case management is an important component of the health care delivery system. It should be made available and used by significant numbers of patients and their families and caregivers in order to promote improved outcomes of quality, cost and access to care. The following bulleted points offer a theoretical framework about case management:

• Holistic and client-centered care
• Mutually agreed-upon goals
• Cost effectiveness
• Working collaboratively with health care providers
• Enhancing client's safety and well-being
• Optimizing outcomes