Case Management Process

Case managers also provide support and information to patients and their families. Next, is utilization review. `Its main objective is to review each case and determine the most appropriate level of services, the most appropriate settings in which the services be delivered, the most cost efficient methods for care delivery and the need for planning of subsequent care. Other methods used for utilization and control are choice restriction and practice profiling' (Douglas, 2003, p.328).

Evidence supports transitional care programs as a means of improving quality of patient care and reducing 30-day readmission rates. Multiple models exist and all center on common goals of early patient identification, disease-specific patient education, medication reconciliation and education, office follow-up and timely coordination of care and sharing of medical records penitent to patient’s case.

The overall process of discharging a patient from a hospital and the transition back home or to a care facility are critical advancements in the overall course of both acute and long-term care. It is important that the hospitals releasing these patients have ensured the proper overall course of care from beginning to end. The lack of consistency with both the discharge process and the quality of discharge planning has led to many avoidable readmissions. To reduce the amount of hospital readmissions, it is imperative that hospitals recognize the need for focused patient care and that programs are being implemented to assist in the care transition.

Case Managers have a challenging job, often dealing with patients, community agencies and facilitating their hospital discharge to the next level of care. They collaborate and communicate with the entire healthcare team and mostly with the patient during the hospitalization process. They act as support for all stakeholders to achieve positive patient outcomes. In this paper, I will be interviewing Ian Mopas, who is a Patient Care Coordinator at Kaiser Permanente in Redwood City about his education, work training, goals, and objectives as a Care Coordinator, and his responsibilities in his organization.

As part of this effort, Kaiser Permanente offers a variety of comprehensive disease management programs to patients. These disease management programs are directed toward chronic conditions (Kaiser Permanente, 2013). There are 4 different disease specific Case Management programs: General, Sickle Cell Disease, Chronic Kidney Disease, and HIV/AIDS. Examples of general diagnoses or conditions that the case management assists with includes oncology, patients with heart failure or high risk diabetes, severe trauma, patients with social service needs, and other high risk patients who have experienced hospital readmissions or are at risk for readmission (Kaiser Permanente,

In order to, differentiate between utilization management and case management using the seven case management standards, it is first important to define each individual component. To begin with, a key component of quality and cost effective care is Utilization Management (UM). Utilization management is a way to assure that the appropriate care is medically efficient, a suitable use of health care services, proper procedures, and is applicable with provisions aligned in the health benefits plan. Case Management engages quality services in a timely coordination of patients’ specific needs in an approach that promotes positive outcomes by means that are cost effective. Case management may be developed during a single health care setting that may then transition throughout the care continuum. The seven standards are key components that described to maximize benefits and minimize the opposition.

The case management process consists of five parts: assessment, treatment planning, linking, advocacy, and monitoring. It is not a linear process and does not follow the order it is written up. There may be some back and forth and returning to certain points.

G: CM met with client for weekly case management session and to update ISP goals.

Case management is a continuous balancing act of judgment calls, making ethical choices, getting along with coworkers, and following legal protocol. It is the duty of the case manager to know how to develop a relationship with both clients and coworkers while still maintain their professionalism. The healthcare professional must always leave their personal opinions at home and provide the same quality of care to all their clients regardless if they have different views, religion, sexual orientations, or cultures. The case manager needs to ensure that the client’s concerns will be put first no matter what, and should also clarify that the as the professional he or she will do all that is necessary to provide the best quality of care to their client.

Case managers play such a key role in the health systems that they are almost considered as the face of patient care.

Case management has case managers who effectively assess my healthcare needs. They also provide support systems to help me. Then, they coordinate, monitor, and evaluate my progress and the services that I receive. It promotes quality and cost-effective interventions and outcomes.

These are the three models of Case Management that are used The role-based case management, the organization-based case management, the responsibility-based case management. The main reason for the difference of the three is for servicing the clients the best and best taking care of their needs. The role-based case management main goal when working with there clients is make sure their clients is receiving the services in which their client needs. Also another important thing is to make sure each service is doing what’s best for the client. An example of this would be making sure the client therapist, rehabilitation are all working together. The next model is the organization-based case management is for clients who have multiple problems and

In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals had to manage efficiently the treatment provided to a client and reduce the client’s length of stay (Jacob & Cherry, 2007). Case management, or internal case management “within the walls” of the health care facilities was created to streamline costs while maintaining quality care (Jacob & Cherry, 2007).

There are many models of case management however there are four specific models which are used for cases involving substance abuse including the brokerage model, intensive case model, rehabilitation/clinical model and the strengths-based model (SAMHSA, 1998. Ridgely & Willenbring, 1992). Within these case management models there are six core functions including client identification outreach, assessment, planning, linking, monitoring, and advocacy. However these models can be differentiated by the extent of client participation, provision and involvement of the case manager (Vanderplasschen et al, 2007). Referring to this particular client the two best models to use would be the brokerage model and the rehabilitation/clinical model.

According to IC & RC, Case Management is defined as, “activities intended to bring services, agencies, resources, or people together within a planned framework of action toward the achievement of established goals. It may involve liaison activities and collateral contacts” (Herdman, John W., 6th Ed.). Case management is a concerted effort of various professionals in the human social services network that assess’, plans, implements, coordinates, monitors and evaluates options required to meet the client’s health and human service needs. It is characterized by advocacy, communication, resource management and promotes quality cost-effective intervention outcomes. The Case Management Process centers on the client and the client’s support system. It is holistic in its approach to the management of the client’s individual and specific situation and that of the client’s support system. It is adaptive both to the case manager’s practice setting and to the healthcare setting in which the client receives services. Case management is not a profession unto itself however; it is a cross-disciplinary and interdependent specialty practice within the health and human services profession. Everyone directly or indirectly involved in healthcare benefits when healthcare professionals and