Successful Case Management Requires a Team Approach

According to the Case Management Association of America, case management is defined as a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality and cost-effective outcomes.  As with almost any process collaboration is key and successful case management is no different.  A team, not silo, approach must be taken throughout every step to ensure effective case management and the best outcome for the patient.
Case management begins with the referral.  The discharge instructions and/or specific orders from both the hospital and the physician must flow to the Plan of Care to ensure the continuum of care is effective.  The physician orders included in the discharge instructions are the beginning of the patient’s Plan of Care and they should correlate with the orders on the 485.

In order to plan the care properly there must be a pre-admissions conference next.  This conference needs to include the admission nurse with the intake RN.  During this conference referral information needs to be discussed, expected diagnoses should be identified, and necessary services need to be determined.
The next step is the admission visit.  During this visit several things need to be explained, including the primary goal of the services and an anticipated discharge date.  Discharge planning must be introduced during the first visit.  Other disciplines that are required to meet the goals and needs of the patient should be identified too.  In addition, a comprehensive assessment of the patient needs to be performed.  The clinician should not just ask the patient questions, but instead the patient should show the clinician the set up in a bathroom or kitchen or read his/her medication bottles.  These kind of activities will enable the clinician to answer questions on the assessment more accurately.  All disciplines on subsequent evaluations and visits need to perform the same type of assessment in order to ensure objectivity and accuracy of patient outcomes.  During this visit the primary goals for the episode or care and for discharge must be established.  These goals must be agreed upon with the patient and caregiver.  They must be realistic, objective and achievable.  Also other disciplines or resources needed to assist the patient and caregiver in achieving these goals must be identified.  These disciplines must be involved in the development of the Plan of Care.

Following the admission visit, the admission nurse, all members of the team and the clinical coordinator must conference briefly.  During this meeting issues identified during the assessment should be discussed.  This interdisciplinary team will develop a proposed plan based on the input of the admission RN, which discusses diagnoses, and projected frequency and duration.  This coordination of care will lead to goal-directed care.  Without this, each discipline is often working towards his/her own independent goals; therefore, not achieving the best overall results for the patient.
The next step involves the Plan of Care and projecting the episode.  Again collaboration is key and interdisciplinary communication should occur after each discipline assesses the patient.  The ultimate goal is to have input prior to the printing of the 485 to ensure it includes discipline frequency, duration and orders.  This is possible if other disciplines see the patient within 48-72 hours.  The care must be goal-driven and established by the team.

As with any case, communication is critical.  It should occur as many times as necessary.  Coordination of care communication needs to cover very pertinent information between the entire team.  Formal case conferences may not occur often enough; therefore, weekly or bi-weekly meetings are recommended and of course, special meetings should occur when any pertinent changes happen.  Issues should not be saved up.  However, communication needs to be brief and concise, and all of it should be documented in the patient’s medical record.  Even sub-contracted therapists need to be part of the communication process and team effort.  They must interact with everyone as if they are employees.
The plan must be evaluated on a regular basis.  In order to ensure the team is in sync, the patient’s progress needs to be regularly assessed and discussed by the entire team.  They may decide that another discipline is needed in order for the patient to meet the goals or the goals and the plan of care may need to be revised.  The physician and receive orders should be part of the process too.

In order to get to the root of a problem a silo approach will not work.  Homecare clinicians are typically very good at identifying patient problems, but often the problem is not fully addressed in an appropriate manner.  Getting to the root of the problem is much easier when working together as a team!  Regular team communication helps identify solutions, revises goals, and more family involvement often occurs, resulting in increased patient outcomes.  Follow up and resolutions need to be documented by everyone and shared with the team.
Discharge or recertification is an important decision that should be goal-driven and discussed during formal agency case conferences.  There should be meetings each month that just focus on a single patient.  These meetings should plan the upcoming month.  They are especially pertinent for patients with ending episodes approaching in 2-3 weeks.  The entire team needs to discuss the situation.  A case conference is always necessary before a discipline discharge, whether it be formal or informal.

In conclusion, successful case management entails caring for the patient, not the wound.  The clinician must coordinate care and collaborate with multiple disciplines of health care professionals.  No one should be acting alone.  The clinician is not only working with the patient, but is also working with the caregiver and sometimes a family too.  An entire team is responsible for follow-through and problem solving with the patient.  Goal driven care by a multi-disciplinary team is the key to enhancing patient outcomes!

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