Compare and contrast the nursing process with processes of case management and advocacy.

Chapter 25

Case Management

1

Define continuity of care, care management, case management, care coordination, population health management, transitional care, integrated care, social determinants of health, and advocacy.

Describe the scope of practice, roles, and functions of a case manager.

Compare and contrast the nursing process with processes of case management and advocacy.

Objectives (1 of 2)

2

Identify methods to manage conflict, as well as the process of achieving collaboration.

Define and explain the legal and ethical issues confronting case managers.

Objectives (2 of 2)

3

Population management

Social mandate

Care management

Utilization management

Critical pathways

Disease management

Demand management

Definitions

4

Case management and the nursing process

Characteristics and roles

Knowledge and skill requisites

Tools of case managers

Historical evidence

Contemporary evidence

Concepts of Case Management

5

Assessment

Diagnosis

Planning for outcomes

Implementation

Evaluation

Case Management and the Nursing Process

6

See Table 25.1, The Nursing Process and Case Management.

6

Case Management Roles

Broker

Consultant

Coordinator

Educator

Facilitator

Liaison

Mentor

Monitor/reporter

Negotiator

Client advocate

Researcher

Standardization monitor

Systems allocator

7

See Box 25.1, Case Manager Roles, for descriptions of these roles.

7

Factors That Demand Case Management Attention

8

Fig. 25.4: Factors that require the attention of the nurse and client in the case management process

8

Knowledge and Skill Requisites

Standards of practice for case management

Evidence-based practice guidelines

Knowledge of the health care financial environment

Clinical knowledge, skill, and maturity

Care resources

Transition planning

Management skills

Teaching, counseling, and education skills

Program evaluation and research

Performance improvement techniques

Peer consultation and evaluation

Requirements of eligibility and benefit parameters by third-party payers

Legal and ethical issues

Information management systems

Health care legislation/policy

Technical information skills

Outcomes management and applied research

9

See Box 25.2 for an expanded list of knowledge and skill requisites.

9

Six “rights” of case management

Right care

Right time

Right provider

Right setting

Right price/value

Right outcomes

Tools of Case Managers (1 of 2)

10

Three tools

Case management plans

Standards of client care and nursing practice

Clinical guidelines

Evidence-based practices

Critical path development gave way to care maps

Disease management

Focus: the natural progression of a disease in high-risk populations

Life care planning

Needs of a client for catastrophic or chronic disease over a life span

Technology driven

Tools of Case Managers (2 of 2)

11

Technology supports the delivery of processes used by the case manager. The technology sector is refining software in the areas of documentation, decision support, dashboard tools, predictive modeling, workflow automation, reporting capabilities, electronic health records, patient engagement strategies and social media, and remote monitoring.

11

Historical evidence

Taylor’s three models

Client focused

System focused

Social service

Contemporary evidence

Model of intensive case management (ICM)

Kolbasovshy (2009)

Reduced readmissions

CARE ONE program: reduced emergency room (ER) visits

2012 Study: decreased acute outpatient and inpatient admissions

Evidence-Based Examples of Case Management

12

Client-focused models are concerned with the relationship between case manager and client to support continuity of care and to access providers of care.

System-focused models, in contrast, address the structure and processes of using the population-based tools of disease management and case management plans to offer care for client populations.

The social service models provide services to clients to assist them in living independently in the community and in maintaining their health by eliminating or reducing the need for hospital admissions or long-term care.

These models offer a solution to unnecessary health care expenses by reducing costs and accessing appropriate health care services.

12

Which model demonstrated a consistent reduction in ER visits, readmissions, and acute outpatient and inpatient admissions in multiple studies?

Social service

Client-focused

System-focused

Intensive case management

Quick Recall (1 of 2)

13

Answer is D.

Intensive case management

Quick Recall (2 of 2)

14

Model of intensive case management (ICM)

Reduced readmissions

Reduced ER visits

Reduced acute outpatient and inpatient admissions

How’d You Do?

15

Advocacy

Conflict management

Collaboration

Essential Skills for Case Managers

16

The advocacy role aims to achieve patient engagement.

By helping patients become invested in their health and care through programs that provide information and tools to empower them to take control and evaluate their care

Advocacy (1 of 2)

17

The definition of nursing includes advocacy: “Nursing is the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations” (ANA, 2010).

17

Process of advocacy

Promoting self-determination in clients

Informing:

Amplifying

Clarifying

Verifying

Supporting

Affirming

Illuminating values

Advocacy (2 of 2)

18

Amplifying occurs between the nurse and the client to assess the needs and demands that will eventually frame the client’s decision. Information is exchanged from both viewpoints.

Clarifying is a process in which the nurse and client strive to understand meanings in a common way.

Verifying is the process used by the nurse advocate to establish accuracy and reality.

The second major process, supporting, involves upholding a client’s right to make a choice and to act on it.

The third process in the advocacy role is affirming. It is based on an advocate’s belief that a client’s decision is consistent with the client’s values and goals.

18

Allocation roles in nursing

Triage

Gatekeeping

Rationing

Systems-level demands

Budget decisions

Staffing assignments

Clinical level demands

Implementing treatment protocols

Advocacy can conflict with allocation.

Limited resources contribute to this conflict.

Allocation and Advocacy

19

Negotiation outcomes

Distributive outcomes

One party gains

Integrative outcomes

Mutual advantages override individual gains

Negotiation stages

Prenegotiating

Negotiating

Aftermath

Conflict Management

20

Negotiating is a strategic process used to move conflicting parties toward an outcome. The outcome can vary from one in which one party gains benefit at the other’s expense (distributive outcomes) or in which mutual advantages override individual gains (integrative outcomes).

20

Establish issues and agenda.

Advance demands and uncover interests.

Bargain and discover new options.

Work out an agreement.

Negotiation Phases

21

Communication is essential but not sufficient.

Joint decision making valued

However, one member should be accountable.

Handling competing expectations

Collaboration (1 of 2)

22

Collaboration (2 of 2)

Goal: to amplify, clarify, and verify all team members’ points of view

23

Legal issues

Ethical issues

Issues in Case Management

24

Liability for managing care

Negligent referrals

Experimental treatment and technology

Confidentiality/security

Fraud and abuse

Legal Issues

25

Autonomy

Beneficence

Fidelity

Justice

Nonmaleficence

Veracity

Ethical Issues

26

Collaboration

Tentative exploration Mutual

acknowledgment

Trust buildingAwareness

Commitment

Consensus

Co lle

gia lity

Amplification Negotiations

Staging of

Clarif i cation

Verifi cation

Com mun

icat ion

Identify Case Management Roles and explain 5 Roles of the Case Manager.

Explain some of the concepts and exemplars with evidence based practice information

Compare and contrast the nursing process with processes of case management and advocacy.