EXECUTIVE SUMMARY

Case management assessments will lead easily into care plans when they’re created more robustly — a 3-D vs. 1-D assessment.

• Instead of just performing the usual disease state assessment, delve into patients’ understanding of the disease and current activities of daily living (ADL) issues.

• Ask follow-up questions up front, saving time and moving to care plans more efficiently.

• Individualize the plan of action based on acuities and priorities.


The case management assessment need not be perfunctory. It could be the way to gain robust information that leads directly to care planning strategies.

This is the idea behind 3-D assessments.

“In our care planning, when we developed a 3-D assessment, we helped case managers focus more concretely and specifically on outstanding patient needs,” says Ellen Aliberti, RN, BSN, PHN, CCM, MS, clinical educator with DaVita Healthcare Partners Nevada in Las Vegas. Aliberti was named the 2017 Case Manager of the Year by the Case Management Society of America (CMSA).

The differences between the usual case management assessment, which Aliberti calls “1-D,” and the 3-D assessment involve detail and depth.

“When you’re doing a disease state inventory, working with a patient and going through items to see if the patient has diabetes, chronic obstructive pulmonary disease, and so forth, in a 1-D assessment, you know the patient has diabetes,” she says. “But the assessment gives you no clues about the patient’s understanding of the disease state or concerns.”

In a 3-D assessment, by contrast, the breakout questions shed more light on how the person is living with diabetes. This assessment finds out whether the person understands the diabetes diet and whether the person needs more assistance in managing medications, Aliberti adds.

The 3-D assessment is an online system that identifies key interventions based on each patient’s responses.

“We developed a series of interventions and goals that are measurable,” she says. “Our care interventions were specific to what we were trying to achieve with the patient, instead of the more global kind of vanilla interventions we were doing before.”

Aliberti describes the following steps to improve case management assessments:

• Collaborate. “We didn’t do this singlehandedly,” Aliberti says. “We worked with the case management department and nursing leadership.”

The initiative started in response to a gap in care management from the health plan audits. “We were not able to demonstrate clearly our assessments and subsequent care planning,” Aliberti says. “The assessment was not naturally guiding care managers into developing a robust care plan.”

The assessment and care plan were separated. The challenge was to develop a more robust assessment that would lead the care manager to a proactive and actionable care plan, producing a 3-D result, she explains.

• Ask follow-up questions up front. Often, in case management assessments, the case manager will ask more detailed questions at second and third visits with patients. But it’s better to ask these questions up front, Aliberti says.

The assessment and care plan steps are more efficient when all important information is gathered at the beginning. For example, if a patient’s chronic health issues include being overweight or obese, it’s better to ask the patient in the beginning about goals regarding weight. Then those goals can be extrapolated to the care plan, she explains.

So from the start of case management, the patient and care manager know that the patient plans to work on weight loss and may have plans to exercise a little each day or cut out evening desserts.

The same can be applied to disease-specific questions. General questions lead into specific questions.

For example, here are some 3-D diabetes assessment questions:

- Can you identify signs and symptoms of when your blood sugar is too low or high?

- Do you understand how to take your medications, what they’re for, and their purpose?

- Are you having any difficulty self-managing your diabetes medication regimen?

- How comfortable are you self-managing your care?

In this 3-D approach, the same questions could be adapted for other disease states. If the patient suffers multiple chronic illnesses, the case manager would ask the patient these same questions for each of those diseases, Aliberti notes.

“This helps our team identify where the pain points are for patients,” she says. “By drilling down and adding a little more robust questioning in the assessment, it can assist the case manager with prioritizing for the care plan and focusing on immediate concerns and issues.”

In another example, if a patient talks about his or her inability to perform activities of daily living (ADLs), the assessment would branch out to 3-D questions to build a complete picture of the significance of the impairment and whether the patient has home assistance, or has the personal resources to secure assistance.

• Assign acuities and priorities to individual goals. All of a patient’s challenges and deficits are built into an individualized plan of care, Aliberti says.

“Our system does care planning around that,” she explains. “We have the ability to assign acuities and priorities to individual goals and interventions that we have developed for the patient.”

Case managers, especially when they’re new to the work, might find it difficult to determine where to start first. Which challenge should be the top priority? With 3-D assessments and care planning, it’s easier to determine the first priority. It’s also easier to outline patient needs and distinguish between short-term and long-term goals.

“You might get the patient the right durable medical equipment for the home, arrange for Meals on Wheels,” Aliberti says. “Then the patient is more open to discussing and working on strategies such as better managing weight or increasing physical activity.”

There are many other issues, such as having the patient meet with a primary care provider, or learning more about nutrition and exercise, or performing advance life planning. But by focusing on items that have an immediate effect on the patient’s day-to-day well-being, the case manager can build rapport with the patient.

The 3-D assessment and care plan assist with identifying these priorities.

Since starting the 3-D assessment and care plan program, the organization has improved its electronic system, using a faster, more efficient product, Aliberti notes.

“In the spirit of continuing improvement, we rolled out a new system,” she says. “It’s helped create a platform where the case manager can discuss the patient’s goal for care in more depth and detail, and it’s also helped improve our results.”