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By Toni Cesta, PhD, RN, FAAN
As RN case managers and social workers, you are key advocates in the delivery of quality healthcare. Your broad skills and training allow you to assess patients’ needs and to work well with families and other members of the healthcare team. Negotiating, collaborating, communicating, team-building, precepting, educating, and consulting are the basis of what a successful case manager brings to the care setting each day. There are skill sets every case manager and social worker needs to be effective. These skills form the foundation of an effective case management professional.
Case management is a collaborative process used to assess, plan, implement, coordinate, monitor, and evaluate options and services to meet individuals’ health needs through communication and available resources to promote quality, cost-effective outcomes.
The RN case manager’s expertise is the vital link between the individual, the provider, the payer, and the community. Successful outcomes cannot be achieved without using specialized skills and knowledge applied through the case management process. Not everyone possesses the necessary skills to become a successful case manager. Case managers and social workers need to be clinically astute and competent in their areas of practice. It is important for case managers to be skilled in the case management process and to learn the assessment skills that make them better able to identify the patient’s actual and potential health problems. This allows them to implement the required interventions to successfully resolve these problems and to evaluate the outcomes of care and responses to treatments.
Assessment is an ongoing and continuous process occurring with all patient/case manager/social worker interactions. It is during the assessment phase that the case manager seeks a better understanding of the patient, the family dynamics, and healthcare beliefs or myths. Generally, an assessment involves three phases: gathering data, evaluating data, and determining an appropriate plan. Case managers use a multifaceted subgroup of skills to accurately assess a patient’s needs:
Case Management Process
1. Patient advocate;
4. Quality improvement coordinator;
5. Resource manager;
7. Financial analyst;
9. Critical thinker;
10. Data manager and analyst.
2. Customer relations;
3. Public speaking;
4. Conflict resolution;
7. Systems thinking;
8. Emotional intelligence.
As an assessor, the case manager must obtain relevant data through thorough investigation. All information related to the current plan must be evaluated with a critical eye to objectively identify trends, set and reset realistic goals, and seek viable alternatives when necessary. A vital case management skill is the ability to recognize a patient’s health problems and formulate action plans based on the subjective and objective data collected during the assessment. The diagnoses express the case manager’s judgment of the patient’s clinical condition, functional abilities, responses to treatments, healthcare needs, psychosocial supports, financial status, and post-discharge needs.
Planning is the next step in managing the patient’s care. Case managers plan the treatment modalities and interventions necessary for meeting the needs of the patient and family. During the planning phase, the case manager, in collaboration with the other members of the healthcare team, determines the goals of treatment and the projected length of stay and, immediately on admission, initiates the transition plan. Determining goals is vital because it provides a clear time frame for accomplishing care activities. Case managers must identify immediate, short-, and long-term needs, as well as where and how these needs will be met.
Planning is initiated on admission or, when possible, before admission. Data are assimilated, plans established, and an interdisciplinary plan of care unfolds.
Throughout the acute hospital, subacute, home care, or long-term care stay, the case manager monitors and re-evaluates the plan for accuracy as the patient’s condition changes. As a planner, the case manager identifies a treatment plan while remaining cognizant of the patient outcomes and minimization of unnecessary costs. The case manager must include the patient and family in decision-making, and consider the patient’s goals as an integral part of the care plan. Alternate plans always must be incorporated in anticipation of sudden shifts in the treatment process or in response to treatments yielding complications.
Implementation and coordination involve building the plan, determining the goals of care, and deciding what needs to be accomplished to create a viable and realistic plan. The case manager’s goal is to give the patient and family the knowledge, attitudes, and skills necessary for the implementation of the plan. Through communication, collaboration, and teaching, the case manager works with the interdisciplinary team to motivate the patient to succeed in meeting the goals of care.
As the patient nears discharge, the case manager can take three steps to improve the chances of effective plan implementation: clarifying the transfer of responsibilities of care, reviewing the plan to ensure that nothing has been overlooked, and making last-minute alterations and arrangements for the immediate discharge period.
The final step in the case management process is designed to measure the patient’s response to the care plan, and ensure the appropriateness of the plan and the quality of the services and products offered.
To achieve successful evaluation and outcomes, the case manager must routinely assess and reassess the patient’s status and progress toward reaching the goals set forth in the plan of care. If the situation is stalled or regressing, the case manager must alter the plan accordingly.
The following important questions must be considered as the evaluation proceeds:
• Were the patient’s needs identified early in the hospital stay?
• Were learning goals identified and teaching documented?
• Were referrals complete and timely?
Taking the time to confirm the plan increases the plan’s effectiveness. Follow-through will help ensure that the goals are met.
• Could the patient/family clearly verbalize the goals of the care plan?
• Were the patient’s/family’s problems resolved?
• Was the patient/family satisfied with the plan and the decisions surrounding the plan?
• Did the patient/family comply with medical advice and follow the case manager’s recommendations?
• Were the services provided appropriately and authorized by the managed care organization?
These questions will help the case manager determine if the discharge plan was effective, and will assist with quality improvement efforts for future patients.
The case manager must use many leadership skills to effectively master the case management process. Because case managers function as problem-solvers, resource managers, and members of the interdisciplinary healthcare team, they should be highly skilled in various leadership qualities. Nurse case managers and social workers must be adept at negotiating, making sound decisions, and resolving conflicts. To perform this successfully, you must use critical thinking and problem-solving skills.
Patient advocacy is one of the most critical elements of the case manager’s and social worker’s role. The patient-case manager relationship is built on trust, to foster mutual respect, and to establish a rapport that facilitates communication among the family, caregivers, payers, and other healthcare team members. As case managers gain a clearer understanding of the patient’s needs and goals, they communicate this understanding to the members of the healthcare team. They also can alter the course of treatment for early discharge or arrange for more efficient home care services. The case manager can be a catalyst for change by empowering the patient or family members to seek solutions throughout the acute care phase and beyond the hospital setting.
Case managers and social workers can best advocate for patients and their families if they apply these techniques:
• Keeping the patient’s best interest paramount in the process of care delivery;
• Recommending, coordinating, and facilitating the most effective plan of care;
• Protecting the rights of patients;
• Communicating to other providers and documenting the patient’s care preferences;
• Facilitating the patient’s and family’s decision-making activities by keeping them well informed of their rights and options;
• Clarifying the goals of therapy and treatment;
• Determining the appropriateness of the post-discharge services and the discharge/transitional plan;
• Ensuring the interventions are consistent with the patient’s needs and goals of treatment;
• Maintaining the patient’s privacy and confidentiality;
• Negotiating on behalf of the patient/family with the managed care organization for service authorizations;
• Facilitating resolution of ethical conflicts;
• Maintaining current knowledge of the legal and ethical requirements and standards of patient care delivery;
• Preventing delays and variances in care delivery.
In case management, problems involving the patient, family, and healthcare provider continuously arise. It is important that case managers solve these problems. The case manager’s ability to provide safe, efficient, and competent services depends heavily on their skills in problem-solving, clinical reasoning, and critical thinking. These skills have one thing in common: They all entail generating solutions to problems, issues, or concerns regarding patient care delivery and options.
Case managers use their clinical knowledge, expertise, and leadership skills. They capitalize on their role as informal leaders of the healthcare team and facilitators of patient care delivery to solve the problems that may arise.
Case managers assess the patient’s and family’s current state and, based on this assessment, envision the outcome by deciding the goals and expected outcomes of the treatments. They implement an action plan to bring the patient and family to the desired outcome. This framework enhances an outcomes-based approach to the delivery of case management services. Usually, the plan is interdisciplinary and implemented only after approval of the healthcare team and consent of the patient and family. Case managers constantly reassess, monitor, evaluate, and revise the plan until the desired outcomes are achieved.
The case manager’s skills in decision-making, clinical reasoning, and judgment must always help the patient to work through the confusion he or she faces in the complex healthcare environment. Case managers answer questions pertinent to the development of the care plan, delivery of care, and evaluation of the discharge plan, such as these:
• Is the current treatment plan appropriate to resolve the patient’s problems?
• Will the case management action plan prevent readmission?
• Are these the best possible treatments for the patient and family?
• Are healthcare team members in agreement with the plan?
• Has the patient or family expressed any disagreements with the plan?
• Should any changes be made to the plan of care or the discharge plan?
• Will the electricity in the home support a mechanical ventilator?
• Does the patient have safe access to a bathroom on the main floor of the house?
• Is it worth the hospital’s financial support to fly a patient out of state rather than incur the cost of an extended length of stay?
• Is the family capable of learning how to perform tracheal suctioning so that their loved one can go home rather than to an extended nursing facility?
Answers to these questions influence the type of care a patient will receive and how it will be accomplished to ensure the best possible outcome for a patient in the most cost-effective manner. Case managers who apply critical thinking and clinical reasoning skills in the decision-making process ensure appropriate, effective, and efficient care delivery. This ensures that the patient and family will receive the necessary support, avoid obstacles, prevent a readmission, and increase the chance of a positive outcome.
Negotiation is a skill that is not primarily taught in nursing or social work educational programs. To be a successful negotiator, a case manager must be a good time manager. Along with managing their own time, case managers must learn to determine what work others can perform in assessing a patient’s needs when preparing a care plan. This understanding allows them to negotiate more effectively.
Negotiation in case management is an everyday occurrence. It is a skill used with payers and providers, with vendors for durable medical equipment, with the patient and family/caregiver, and even with physicians reluctant to opt for a home care discharge plan or placement in a long-term care facility. Fair negotiation requires trust, rapport, and complete honesty about a patient’s care needs.
Successful negotiation is achieved through preparation and presenting the facts clearly and succinctly. To know if you have negotiated your case well, you must be a good listener and observer; otherwise, windows of opportunity can be missed.
On the financial side, we know all too well that healthcare environments are committed to doing more with less and at a lower cost. A case manager’s financial prowess is a must in these times of cost containment. Case managers must work with financial support personnel and keep them abreast of a patient’s insurance health benefit.
This month, we began our discussion about the skills needed to be an effective RN case manager or social worker in today’s complex healthcare systems. The skills needed far exceed those acquired through one’s professional licensure, and require expanded knowledge and skill sets to become a proficient case management professional. Next time, we will continue reviewing the leadership skills and communication skills needed to become a successful case manager.
Financial Disclosure: Author Melinda Young, Author Jeanie Davis, Editor Jill Drachenberg, Editor Jonathan Springston, Editorial Group Manager Leslie Coplin, and Nurse Planner Toni Cesta, PhD, RN, FAAN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.