Chapter 15: CASE MANAGEMENT AND ADVANCED PRACTICE NURSING Flashcards
CASE MANAGEMENT DEFINED
“A collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual’s health needs through communication and available resources to promote quality, cost-effective outcomes.”
“A dynamic and systemic collaborative approach to providing and coordinating health care services to a defined population. It is a participative process to identify and facilitate options and services for meeting individuals’ health needs, while decreasing fragmentation and duplication of care and enhancing quality, cost-effective clinical outcomes.”
HISTORY OF CASE MANAGEMENT
Early 1900s — federal government mandates the United States Public Health Services to develop a system of case management with the community as the client (large environmental problems)
1935 — individual case management needs addressed through the Social Security Act
Proliferation of such services for the disabled, veterans, mentally ill, and in public health
1980s — initiative of prospective payment through Medicare
1993 —requirement filed for workers’ compensation
ADVENT OF THE 21ST CENTURY
Case management introduced for private sector insured with high cost needs
2010 — The Patient Protection and Affordable Care Act (PPACA)
-Accountable care organizations (ACOs)
-Medical Homes
GOAL OF CASE MANAGEMENT
Controlling costs while delivering quality and consumer-preferred care
CASE MANAGEMENT COMPETITORS
Registered nurses / APRNs
Social workers
Physical therapists
Psychologists
Physicians
Mental health workers
Pharmacists
Teachers
WHAT GOVERNS THE CHOICE OF CASE MANAGER?
Setting of care delivery
Type of care coordination required
Payer’s preference
Federal and state program mandates
The cost of a particular professional
THE NURSE AS CASE MANAGER
Clinical knowledge and skills
Astuteness about the health-care delivery system
A holistic perspective on client care
Readiness to defer to the client’s preferences
DIFFERENTIATING NURSES IN CASE MANAGEMENT
Baccalaureate preparation
Master’s–advanced practice (NP or CNS)
Master’s–case management preparation
MOST COMMON COMPETENCIES OF A NURSE CASE MANAGER
Providing patient advocacy
Serving as guardian of confidentiality
Acting as case selection expert
Fulfilling care coordinator function
Performing assessment and reassessment
Serving as discharge planner
Delivering follow-through
Providing utilization management
Employing knowledge of insurance structures/benefits
Engaging in cost-benefit analysis (fiscal advocacy)
Exercising negotiation skills
Providing clinical expertise, including experience-based intuition
Serving as a critical thinker
Utilizing professional skills (knowledge of standards and legal issues, research ability)
Performing outcomes management
Employing interpersonal skills (communication, assertiveness, collaboration, tact/diplomacy)
Using organizational skills (time management, marketing/networking, prioritization, report writing)
NURSE CASE MANAGEMENT MODELS
Hospital based
Hospital-to-community based
Community based
Chronic care management
Payer based
Independent contractor
OUTCOMES OF CASE MANAGEMENT
Patient knowledge
Patient involvement in care
Patient empowerment
Patient adherence
Coordination of care
REIMBURSEMENT
The Current Procedural Terminology (CPT) coding system recognizes case management; therefore, APNs may bill for the time devoted to these services in the outpatient setting
CERTIFICATION
Interdisciplinary case management
Nursing case management
No specific certification for advanced
practice case management
Clinical specialty certification
Case management administrator certification
