Case Management Insider
The case management process in effective and efficient action
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
Case management follows a process, not unlike the clinical nursing process or social work process. By following a process, case managers can function more effectively and efficiently. They will also have a higher likelihood of achieving meaningful outcomes for themselves, their patients and their organization. A process is defined as a systematic series of actions, changes or functions directed to some end. Like some processes, the case management process is not a linear one. Rather, it is a series of non-linear steps that may sometimes go out of order or may have to be repeated. This is to be expected in the field of case management. Algorithms are processes that cannot be deviated from under any circumstances. They are considered "hard wired." The case management process, however, is not hard wired, and may take a variety of twists and turns as the patient moves toward transition or discharge from the hospital.
As we have discussed in prior issues of Case Management Insider, case managers and social workers perform a series of functions within the roles that they are responsible for. These functions are performed using the case management process to guide the case manager toward the expected goals that they are aiming to achieve.
Selection and screening
The first step in the case management process is the selection of patients in need of case management interventions. In the hospital setting, the selection of patients will be dependent on the type of model in place. In order to know the expectations of the case manager in this first step, the case manager will need to know the structure that they are working within, and how patients are assigned to them.
In some hospitals, every patient is followed by a case manager. If the hospital's model is designed in this way, then the case manager's caseload or selection of patients is dependant on their bed, unit assignment or perhaps geographical area that they are responsible for. In other models, the case manager may be responsible for managing patients with specific diagnoses or specific payer sources. Some may follow a product line such as trauma or cardiac services. Others may be responsible for patients under a particular physician or hospitalist. In each of these approaches, it is fairly clear how the patients are assigned to a specific case manager. If the hospital's model is that every patient is followed by a case manager, then there is no need for the case manager to screen the patient prior to assessing them. This step is eliminated. The same logic would apply to models linked to a specific diagnosis or physician. By virtue of the linkage, the case manager automatically has that patient in their caseload.
If your model is not an "all comers" model, then your hospital must use high-risk criteria to determine which patients would be followed by the case manager. If your hospital uses this approach, a screening will need to take place in order to determine whether or not the patient meets these pre-determined high-risk inclusion criteria. With this type of approach, the case manager must collect relevant information to determine whether or not the patient meets the pre-selected inclusion criteria.
In some instances, a member of the healthcare team may make a referral to the case manager directly. From either point, the case manager must then collect relevant data from a number of data sources. This data will help the case manager to determine whether or not they will pick up the patient as an active member of their caseload.
Data sources for case management screening
Multiple data sources are needed to be accessed as the case manager works through the screening process. Data sources include:
- the patient's current medical record;
- the patient's prior medical record;
- the patient's out-patient record if available;
- other members of the healthcare team;
- the patient and family.
This information is then compared to the predetermined inclusion criteria. If there is a match, the patient is selected to be followed by a case manager while they are in the hospital.
The screening process is the first step in identifying the case manager's caseload of patients. The number of patients to be followed is also dependent on how the department's infrastructure is designed.
High risk criteria
For models where not all patients are followed by a case manager, this screening criteria list can be used to determine whether the patient needs case management services while they are in the hospital:
- specific diagnoses;
- specific physician;
- specific payer sources;
- multiple physicians involved in case;
- non-adherence issues;
- complex discharge educational needs;
- frequent emergency department admissions;
- high tech needs such as ventilators, IVs;
- discharge placement needs such as home care, rehab;
- multiple system requirements for home care;
- adult day care needs;
- frail elderly;
- guardianship or conservatorship;
- medically indigent (under or uninsured);
- potential / suspected abuse;
- hospice;
- frequent readmissions;
- additional specific issues.
Each hospital has to determine its own "high-risk" criteria based on its own unique patient population and community issues.
Patient assessment and diagnosis
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
Once the patients requiring case management have been identified, the case manager must then perform an assessment. The assessment is the key to determining what interventions the case manager and social worker may need to apply in order to achieve the expected outcomes for the patient. The case management assessment differs from the traditional clinical assessment completed by the staff nurse or the physician. It encompasses additional elements that are needed to determine the case management plan for that specific patient. The three broad categories of the assessment include clinical, psychosocial and financial.
The first question that the case manager must always ask is, "why is this patient in the hospital?" The answer to this single question will provide the case manager with a significant amount of important information.
For case management, why the patient is in the hospital may have nothing to do with the admitting diagnosis. A family member may have left the patient in the emergency department. The patient may be unable to care for himself or herself at home. The patient may have neglected to take one or more doses of medication at home, thereby resulting in an exacerbation of their illness.
The patient's clinical picture must be taken within the context of the psychosocial and financial information. For example, the patient may not have taken their medication because they could not afford the co-pay, or the patient may be confused or unable to care for themselves in their current living situation.
Where does the data come from?
The case manager will harvest data and information from a number of sources. This process should be structured so that by the time that the case manager interviews the patient and family, they will have already gathered the information that will help them to ask the right and most pertinent questions of them. If possible, the case manager should review the patient's prior clinical record. As more hospitals move toward electronic review the current medical record, sometimes not all relevant information is available early on. This should not delay the case management process however.
In addition to obtaining information from the current and prior medical records, the case manager should speak with the physician. This will help the case manager understand what the physician's reason for admission is, and what the anticipated plan of care is, as well. The case manager should also discuss any findings that the staff nurse may have that will inform the discharge plan as well as the in-patient stay.
If the patient was admitted via the emergency department, the case manager will want to speak with the emergency department case manager and/or review the emergency department case manager's notes.
Using the data for the discharge plan
All the information gathered by the case manager will help to determine the initial discharge plan. Eighty percent of the time this initial discharge plan will become the final discharge plan. By doing an early assessment, the case manager can expedite the process so that there are no delays as the patient moves toward discharge from the hospital. The patient's clinical issues and needs must be crossed match with their psychosocial and financial issues. Only through the integration of this information can the case manager coordinate the stay and the discharge plan adequately.
Discharge destination correlations
The majority of the time, the anticipated discharge plan can be based on where the patient was admitted from, whether or not they have a chronic condition or if they are having surgery and what type of surgery.
- admitted from nursing home — discharged to nursing home;
- admitted with prior home care use — discharged with home care;
- admitted with chronic condition — discharged with home care;
- admitted for surgery — discharged with home care.
These correlations will be correct 80% of the time.
A standard case management assessment tool can be used to help collect and organize all the relevant information that the case manager needs to make a comprehensive plan for the in-patient stay as well as the best discharge plan possible.
Next month, we will continue with the additional steps in the case management process.
Performing the necessary assessments
By Toni Cesta, PhD, RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY
Assessments that must be performed include clinical, psychosocial and of course, financial. The clinical assessment includes the gathering of relevant clinical information that will help the case manager in the performance of the roles that we have discussed in prior issues of Case Management Insider. This data should include the daily clinical needs of the patient. These needs will be coordinated and facilitated by the case manager, so the case manager must know exactly what the plan is for each day that the patient is in the hospital as well as the plan following the acute care episode. This information also assists the case manager in communicating with the third party payer in the performance of their role in utilization review. By having the most current clinical information, the case manager is in a great position to provide the most complete information to the third party payer, thereby increasing the chance of approval for reimbursement. (For an example of a case management admission assessment, see box.)
Psychosocial assessment
The psychosocial assessment has two principal goals. The first is to help to identify any immediate needs that the patient or family may have while the patient is in the hospital. The second is to identify any barriers to a safe and appropriate discharge from the hospital.
The case manager can complete the initial psychosocial assessment. This assessment includes the family as well as the patient. Once the case manager has identified any potential psychosocial problems or issues, a referral can be made to the social worker for follow-up.
For example, if the family is having difficulty coping with the patient's illness and hospitalization, a referral to the social worker would be appropriate. If the family had been caring for the patient at home but are no longer able to do so, this too would warrant a referral to the social worker.
The case manager must also assess the patient for financial risks or concerns. These may include insurance coverage issues, coverage for continuing care services in the community, Medicare lifetime reserve days, the need for Medicaid, and so on. The case manager should review this information in the context of the reason for hospitalization as well as the patient's benefits following discharge. The best discharge plan may not be able to be implemented if the patient does not have coverage for that service in the community.
Case management follows a process, not unlike the clinical nursing process or social work process. By following a process, case managers can function more effectively and efficiently.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.