Continuum Of Care: A Case Study

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.

The Case Management program is offered by Kaiser Permanente to support members with complex medical, psychosocial, and care management essentials. This specialized service is provided by case managers. The case managers are either Registered Nurses who are certified in case management or qualified Social Workers. Case managers provide necessary information and education to promote understanding, reduce the chance of possible complications, and facilitate effective and proper delivery of care and services.

In my interview with Stacy she says, “A case managements goals was to meet the needs of the individuals and the families” (Downing, 2015). It all ultimately depended on the situation and how long you have known the family that you typically access the patients and use those challenges to develop a plan in which the patient has helped you formulate. The goal is to in a therapeutic way engage the patient and their families in their own plan or progress in which working within their skill level and readiness to change and build upon the current

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.

The case managers' role is diverse. It consists of screening, assessing, planning, implementing, following up, and evaluating the situation of the foster child assigned. They are essential in the child's case plan by acting as a liaison that connects the foster parent and the state. Besides bridging the gap, they also make sure to facilitate the appropriate resources.

In this setting the case manager would work best using the role-based case management model and with their primary role to function as a generalist, “This role, widely used in human service delivery, focuses primarily on providing the services that can be delivered by a helper with knowledge and skills applicable to a range of clients in various settings” (Woodside, & McClam, 2013. p 75 para 3); following the role of generalist the case manager would likely take on the roles of counselor, care coordinator, problem solver, and record keeper. Under the role of counselor and broker an intervention strategy that could be implemented is for the case manager to meet with the individuals on their caseload and after completing an assessment create a treatment plan that would help to resolve any barriers that the individual may be facing that would hinder their ability to attend their medical appointments and strict regimen of medications, the case manager would then continue to hold regular meetings with their clients to ensure the individual treatment plan is being adhered to (Wohl, et al. 2011). The problem a case manager may see while trying to help provide services to people living with HIV/AIDS under the model of role-based manager is that the case manager may be working for an agency with very limited resources which can then severely restrict the benefit of the program and leave the case manager feeling frustrated and overwhelmed and the though there may be a wide array of services that may be needed, the agency can only afford to focus on the cheapest. If the agency does happen to be well funded then the benefits of role-based case management model mean that the individual will only have the one contact person to reach out to and allows for a better relationship to develop which makes for a more effective case manager (Woodside, & McClam,

Part of a case manager (CM) duty is to have broad knowledge of care delivery and reimbursement methods to adequately perform case management duties for clients. The CM must recognize the clinical and financial funds available for the client and what the eligibility criteria for getting those resources. By getting a better understanding will allow the CM to ensure the client gets the proper care in the most cost-effective way. Reviewing the 2014 revise knowledge domain the one domain I reviewed was reimbursement. (Care Delivery & Reimbursement Methods, 2016) The Healthcare Reimbursement domain involves knowledge related to different types of reimbursement and funding systems to include sources and methods related to utilization review and management

b. Think specifically of learning and behavior. Pretend you are in your first year of

The BSN case manager is responsible for collaborating with the patient, physician, RN, CNA, family and other ancillary departments. She is also involved with the more complex aspects of the daily care and establishing a relationship with the patient and family.

Case Management Services: Russ, Case Management is a service that helps to improve client’s wellbeing and overall health. Supporting them professionally, providing them with resources that are available in your community. Case managers also help clients develop cost-effective interventions and to

In addition to the core Care Management end-user training for case managers, this paper documents training and knowledge transfer sessions that were conducted for:

Continuum of care is a system that guides patients throughout their lives with a variety of health services including physical health, mental health, and social services (HIMMS, 2014). Under this specific title, a continuum of care includes prevention programs, physical activity programs, community-based services, routine health screening, and healthy lifestyle counseling (HIMMS, 2014). For example, a nurse navigator assists clients in the complexity of the health system and bring them access to the right services at the right time to improve or manage their overall health (CARA, 2008). With ACA adding coverage under Medicare, Medicaid and private insurance to preventative services and health screenings, it provides a pathway for patients to

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

According to Holtrop, Potworowski, Fitzpatrick, Kowalk, & Green, (2016), care management hire a care manager to give appropriate care to the patients, see the patients individually to help them fix the goal and achieve better care, medicine compliance and also for the patients with chronic illness. The care manager see the patients to fix the goals and help to achieve that Care management is essential piece towards improving the patient’s care and also helps patients to get better medical services. It could also help nurses or caregivers to give exceptional care service to the patients. Care management is possible way to take care of chronic disease.