case management

Care management is a health care delivery process that helps achieve better health outcomes by anticipating and linking clients with the services they need more quickly.
The purpose was to promote quality and ensure appropriate use and costs of services.
Typically these involved clients with reduced self care capacity and whose diseases and treatments were intense
Care management strategies include:
1. Utilization management
attempts to promote optimal use of services to redirect care and monitor the appropriate use
of provider care/treatment services for both acute and community/ ambulatory services.
clients who have repetitive readmissions (i.e., they fail to respond to care) are often referred to care management programs.
2. Critical pathways and maps, which were more popular in the early 2000s, are tools that specify activities providers may use in a timely sequence to achieve desired outcomes for care. Case management services are used for clients with specific diagnoses who may have high-use patterns,
non-compliance issues, cost caps (e.g., threshold expenses)
3. Disease management constitutes systematic activities to coordinate health care interventions and communications for populations with conditions in which client self-care efforts are significant For example, diabetes, asthma,
and depression are typically targeted by providers and insurers.
.
These programs have evolved largely as initiatives in managed care organizations.
4. Demand management seeks to control use by providing clients with correct information and education strategies to make healthy choices, to use healthy and health-seeking behaviors to
improve their health status, and to make fewer demands on the health care system
Although the activities in case management
may differ among providers and clients, the following five goals are shared:
• To promote quality case management services to populations
• To reduce institutional care, fragmentation of care, and safety gaps in transition of care while maintaining quality processes and satisfactory outcomes
• To manage resource utilization through the use of protocols, evidence-based guidelines, utilization, and disease management Programs

• To control expenses by managing care processes and outcomes
• To improve adherence to guidelines for quality case management by clients and providers
Legal Issues
Case managers today face pressure to control costs, to use evidence- based guidelines for practice, and to reduce risks for legal liability.
They are vulnerable to legal risks because of inadequate preparation, changing legislation and policy, insufficient support, and unclear role expectations
Liability concerns of case managers exist when the following three conditions are met:
(1) the provider had a duty to provide reasonable care,
(2) a breach of contract occurred through an act
or an omission to act, and
(3) the act or omission caused injury or damage to the client.
Case managers must strive to reduce risks, practice wisely within acceptable practice standards, and
limit legal defense costs through professional insurance coverage.
THE NURSING PROCESS AND CASE MANAGEMENT
Assessment
CASE MANAGEMENT PROCESS
• Case finding
• Identification of incentives for target population
• Screening and intake
• Determination of eligibility
• Assessment
ACTIVITIES
• Develop networks with target population
• Disseminate written materials
• Seek referrals
• Apply screening tools according to program goals and objectives
• Use written and on-site screens
• Apply comprehensive assessment methods (physical, social, emotional, cognitive, economic, and self-care capacity)
• Obtaining consent for services if appropriate
Diagnosis
Identification of problem/ Opportunity
ACTIVITIES
• Hold interprofessional, family, and client conferences
• Determine conclusion on basis of assessment
• Use interprofessional team
Planning for Outcomes
• Problem prioritizing
• Planning to address care needs
• Identify resource match
ACTIVITIES
• Validate and prioritize problems with all participants
• Develop goals, activities, time frames, and options
• Gain client’s consent to implement
• Have client choose options
Implementation
• Advocate clients’ interests
• Frequent monitoring to assess alignment with goals and changing nature of client needs
ACTIVITIES
• Contact providers
• Negotiate services and price
• Adjust as implementation is needed
• Document processes and monitor progress
Evaluation
• Measure attainment of activities and goals of service delivery plan
• Continued monitoring of client status during service
• Reassessment
• Bring closure to care when client needs are achieved or change
• Discharge appropriately
ACTIVITIES
• Ensure quality of transitional communication and coordination of service delivery
• Monitor for changes in client or service status
• Examine outcomes against goals
• Examine needs against service
• Examine costs
• Examine satisfaction of client, providers, and case manager
• Examine best practices and outcomes for this client