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Main Healthcare, Pharmaceuticals & Biotechnology Healthcare and drugs Case or Care Management, 2nd edition (2007 Update)
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Case or Care Management, 2nd edition (2007 Update)

DateJan, 2007
Pages137
Price / format€70 / Electronic
€70 / Hard Copy

€70 

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Abstract:
 Case or care management is an outgrowth of the recognition that mechanisms to coordinate a relatively inefficient health care delivery system were needed to improve the overall quality of care as well as to reduce duplicative and unnecessary services. While utilization management (UM) is the evaluation of medical necessity, appropriateness, and efficiency of the use of health care resources, case management (CM) is a collaborative ongoing process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s needs through the coordination of available resources to support those specific care needs. UM is reactive, responding to requests for health care services while CM is proactive in the identification of needs and resources to meet those needs. UM has no or a very limited interaction with providers and patients while CM has ongoing communication. Both UM and CM address the appropriate and necessary utilization of health services at the most appropriate level of care, efficiency of care and quality of care.

The terms “case management” or “care management” has taken on myriad meanings and connotations over time. In general, CM involves a comprehensive system for complex care needs identification followed by the efficient management of an episode of illness that includes assessment, planning, implementation, coordination, monitoring, evaluation/reevaluation, discharge functions and planning for continuity of care similar to other health care quality processes. CM should minimize fragmentation of care and maximize the coordination of needed services. CM must be designed to meet the needs of an individual patient.

Utilization reviewers are often called case managers, and in some cases, do perform some elements of case management for complex and high-risk cases where interdisciplinary management and resources are needed. Worker’s compensation programs use case management to coordinate the physician and other provider care with vocational training and other need services related to the worker’s disability. The goal of case management is to promote quality, cost-effective optimal outcomes and coordinate care across the continuum of needed supportive services, medical and in some cases, non-medical. Outcomes are driven by medical care only in part – financial, psychosocial, lifestyle and related issues often play a major role.

There are 137 pages of policies, procedures and strategies that ‘work’ to improve quality, efficiency of care while controlling unnecessary costs. Specific case management effectiveness data by disease entity.







Table of contents:
 Preface, Disclaimers, Other important information

Introduction to case or care management

Geriatric Case Managers

Patient Selection for CM

Case Management Program

CM - What is it?

CM skills

CM Information Systems

Mentoring

CM - policy and procedures

Social Work Case Management Competency Requirements

Certification requirements for social work case manager

Case Management Accreditation

Hospital UM/Care or Case Management Staff Functions

Roles and responsibilities of hospital-care focused UM staff

Roles and responsibilities of ambulatory-care focused UM staff

Primary case manager

Specialty CM/Clinical Nurse Specialist - roles and responsibilities

Criteria for specialty case management referrals and case acceptance

Specialty case management - policy and procedures

Telephone case management

Criteria for Social Service/Counseling Management -

Specialty case manager - Case closing

Intake Form - example content

Specialty case manager - Discharge form

Hospital case manager - UM variance reports

CM: Skilled Nursing Facility

Skilled vs Custodial (non-skilled) Levels of Care Services

Custodial Level of Care – Questions and Answers (handout)

What are the concerns about SNF admissions?

CM: Home health and hospice services

Patient Choice re: HHA Ownership Disclosure Form – Example

Inappropriate Admissions - Change in Status

CM: Discharge planning P&P

Hospitalist program post-discharge transitional management of care

CM: Homebound program

Homebound program assessment survey

High risk screens for new health plan members

CM: New patient preliminary screening triggers and actions

CM: Outcome Measures

CM: Addiction Management

Case Management in the ED for High Utilizers

High risk case detection for focused case management

CM Screen example for high risk patients

Case management for disease specific referral programs

Cases (example list) to screen or target for CM services

Congestive heart failure CM

Diabetic Case Management

Nutritional case management

Heparin-coumadin conversion program

HIV – Case Management

Hip Fracture – Case Management

Obstetrical case management

End-of-life care - case management

Mental Health Case Management Services - protocols, policy

- CM triggers for the patient requiring behavioral health care

- CM: Behavioral Healthcare – Policy example

- Clinical case management

- Community-based services

- Depression Care - Case Management

- Children/Adolescent Case Management Services - Oklahoma Foundation for Medical Quality (OFMQ) Case Management Program

- Client Assessment Record (CAR)

Case Loads – 2001 survey data

Position descriptions

Hospital Director, Case Management Services

Case Manager, Primary Care/Ambulatory Care

Case Manager, Hospital

Case Manager, Specialty Care

HIV/AIDs Nurse Case Manager

Case Management Coordinator

Social Worker, MSW

Social Worker Case Manager Competency Requirement List

Social Work Director

Discharge Planner: Position description

CM Candidate Screening Tool

CM: Duties

CM Credentialing Resources

CM Plan - example

Care coordination program - example

CM-related organizations

CM references and resources

Case-mix adjustment; severity of illness resource

Web Sites – Case Management, Nursing

CM Notes




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