The Standards of Practice for Case Management, a Foundation for Care Coordination across the Entire Care Continuum.

Transcription

1 Case Management Society of America 6301 Ranch Drive Little Rock, AR T F E cmsa@cmsa.org The s of Practice for Case Management, a Foundation for Care Coordination across the Entire Care Continuum. Mary McLaughlin Davis, DNP, MSN, APRN, ACNS-BC, CCM and Lori J. Schmitt RN, MBA The root cause of many patient safety problems, high-cost medical care and unnecessary readmissions can be traced to transitions of care, or the lack of meticulous planning in that area. Care coordination is the linchpin that improves quality of care for patients. For case managers, safe and secure care coordination has been a priority for over 20 years, and many have dedicated their professional lives to improving care transitions. Organizations such as the National Transitions of Care Coalition (NTOCC) are working to provide a platform for care coordinators with tools that are easy to use and that make a difference in patient s lives. Determining how case managers can better perform care coordination is a topic which, up until recently, has received little attention; however, it has gained national interest during this critical time of healthcare reform. The National Quality Strategy Agenda spotlights care coordination as one of the six priorities they wish to address, along with: safer care, patient engagement, effective prevention and treatment, best practices in healthy living and the development of new healthcare delivery models. Because of this laser focus, considerable time is devoted to determining how care coordination will be defined and measured (Lamb, 2013). Care coordination is defined by The National Quality Forum (NQF) as a function that helps ensure that the patient s need and preferences for health services and information sharing across people, functions, and sites are met over time (NQF, 2006). The Agency for Healthcare Research and Quality (AHRQ) offers the following description as a function of care coordination and states it is an essential component of a medical home and/or Accountable Care Organization (ACO): Care is coordinated or integrated across all elements of the complex healthcare system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it, in a culturally and linguistically appropriate manner (McDonald et al., 2008). Due to rapid changes and regulatory mandates, many healthcare organizations are developing an integrated care coordination process throughout their institutions and levels of care delivery. Although case managers have had a presence in hospitals since the early 1990s, they have been housed literally and figuratively in the basement, and have been known primarily for their utilization review expertise. Many experienced hospital nurses and social workers have assumed care coordination roles and have been largely unrecognized. Insurance companies and workers compensation carriers have provided care coordination services to patients, as well as clients often working in silos due to the lack of collaboration between providers and payers. Professional certifying organizations as well

2 Page 2 as universities offering nursing and social work degrees did not previously deem care coordination as a graduate level of expertise. In today s healthcare environment, case managers need both the tools to do their job as well as national professional association standards in order to stay compliant with standards and improve patient outcomes. The first course in the Case Management Society of America s Career and Knowledge Pathways educational program, CMSA s of Practice: The Foundation for Professional Excellence in Coordination of Care Across the Continuum, addresses regulatory compliance, helps to improve patient outcomes and establishes uniformity in the workplace. Since the program is based on CMSA s s of Practice for Case Management, proficiency in these measures ultimately leads to decreased readmissions and better financial outcomes. The current state of healthcare reveals that care coordinators are highly desirable and critical to remedying medication errors and preventing unnecessary readmissions. The patient experience survey by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) offers two domains for discharge and care transitions that are directly related to the quality of care coordination services provided. Many physician practices and outpatient centers do not formally provide care coordination, nor do they have designated and licensed professionals providing the service. The fee-for-service payment system is a major detriment to care coordination services in traditional practice settings. However, with reimbursement for care coordination services closer to becoming a reality, it is imperative to establish accepted qualifications for care coordinators (Hong, Abrams, Ferris, 2014; Marion, 2010). In the past, nursing homes provided skilled and long-term care by enlisting their social worker to make arrangements for home care as well as the necessary equipment for their patients discharge. However, care coordination was not practiced beyond making referrals to home care and durable medical equipment companies. Nursing homes infrequently made follow up phone calls or home visits. CMSA membership extends across all healthcare settings, including payer, provider, government, employer, community, and home. It is the largest and most influential group of Case managers in the country. - Cheri Lattimer, RN, BSN, Executive Director, Case Management Society of America Care coordination is clearly outlined in integrated delivery networks where value-based healthcare is the predominant paradigm. CMSA s s of Practice for Case Management are reflective and consistent with the integrated health networks overall mission and vision. CMSA s s includes language that emphasizes care coordinators role in care delivery of an integrated health network. As an organization, CMSA is positioned to understand and interpret standards relating to care transitions across the continuum.

3 Page 3 Unfortunately, readmissions are at the heart of value-based healthcare. Medication errors are a predominant reason for unnecessary readmissions; clinically-significant medication errors affected 50.8 percent of patients during the first 30 days after hospital discharge. Patients discharged without adequate medication dosing or an accurate understanding of how to take their prescribed medications are at risk for avoidable hospital readmissions (Kripalani et al, 2012). The high prevalence of medical errors associated with transitions of care from hospital to home is associated with an increased risk of re-hospitalization (Moore, Wisnivesky, Williams, McGinn, 2003; Report to the Congress, 2007). The proposed 2012 Medicare Transitional Care Act mandates that each discharged hospital patient must receive a comprehensive medication management plan. This plan includes assessment and consultation with medical providers to ensure that medications are necessary and appropriate, as well as free of discrepancies with potential allergies, co-morbidities and other prescribed medications. The legislation includes required individual and family counseling about medications (Blumenauer, Petri, & Scttakowsky, 2012). In 2013, The Centers for Medicare and Medicaid Services (CMS) provided new outpatient coding allowing the physician, advanced practice nurse or physician assistant to bill patients transitioning from the hospital or nursing facility to home for transitional care management services. With the advent of the increased scrutiny that care managers and coordinators face, the need to provide an evidence-based foundation for care coordination practice is increasingly essential. ACOs, hospitals, and insurance companies have a responsibility to provide a comprehensive orientation and onboarding experience, as well as continuing education on every aspect of the case manager s or care coordinator s job. This is especially true with their increased responsibility and accountability for specific patient outcomes. Organizations that provide this all-inclusive commitment to their staff demonstrate the value they place on their patients, employees, and practice (Gesme, Towle, Wiseman, 2010). s of practice are authoritative statements that reflect the commitment of the professional community to their patients, clients, organizations and constituents. The document Nursing: Scope and s of Practice describes the level of care or performance common to the profession of nursing by which the quality of nursing practice can be judged. CMSA s s of Practice for Case Management includes topics that influence the practice of case management in the current healthcare environment. The s focus on transitions of care, and facilitates complete transfers to the next care setting provider that are effective, safe, timely, and complete (Hill, 2014; Marion, 2010). s of practice are required by all professionals and are developed to assist the decisions of patients, clients, and practitioners about appropriate healthcare for specific clinical circumstances (Graham, Harrison, 2005). CMSA, established in 1990 with nearly 10,000 members today, is the recognized leader and trusted professional association that exists to close gaps in healthcare performance by translating the best science and knowledge into effective continuing professional development. CMSA s educational resources create uniformity and consistency in standards of practice for all case managers; additionally, they allow case managers to obtain significant work-applicable continuing education to address their scope of practice as defined by their job descriptions, standards of practice and legal requirements. CMSA recognizes and works in tandem with the regulatory bodies that accredit all levels of healthcare providers. The CMSA s compliment and support the principles of two

4 Page 4 important credentialing entities: the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission (CMS, 2013; Joint Commission, 2014). This alignment is demonstrated in the CKP Crosswalk document, linking the CMSA s with the CMS and Joint Commission standards and criteria for care coordination. The s of Practice for Case Management further detail the role of the care coordinator and outline the specific practice standards that the legislators, regulator, legal counsel, and the judiciary system can reference. CMSA s s of Practice for Case Management are also referenced by URAC in its interpretation of the standards. CMSA s Career and Knowledge Pathways (CKP) educational program has the potential to break new ground in care coordination, healthcare education and training. CMSA is the source of evidencebased content for care coordination professionals, healthcare workers, students, caregivers, and patients. Through CMSA s careful planning and implementation, CKP uses contextual learning, spurring learners to leverage their existing knowledge and advance opportunities for personal and professional development. CKP incorporates learner reflection to consciously translate newlyacquired information into long-term, integrated knowledge. Contextual learning is reality-based, outside the classroom and offered within a defined context (McHugh, Lake, 2010; Baker, Hope, Karandjeff, 2009). The s of Practice for Case Management align with the regulatory compliance mandates impacting the entire healthcare continuum. The interpretation and understanding of these standards is paramount to obtaining successful outcomes in the care delivery of patients. Case managers new to the profession benefit from learning the case management s through the interactive CKP program. Experienced case managers benefit from CKP through a review of the CMSA s of Practice in relationship to the standards of the credentialing bodies. CMSA s s of Practice are brought to life in the CKP program, and case managers as well as care coordinators that purchase the course will become prepared to articulate to patients, clients, families, payers, and credentialing organizations how the s define, drive, and enhance the practice of care coordination. To learn more about CMSA s s of Practice for Case Management, visit To watch a demo and receive more information about CMSA s Career and Knowledge Pathways educational program, visit

5 Page 5 References American Nursing Association, Professional s- information retrieved from website, September 19, 2014, Baker, E., Hope, L. & Karandjeff, K. (October, 12, 2014). Contextualized teaching and learning: A faculty primer, RP group center for student success. Case Management Society of America, s of Practice for Case Management, Revised 2010 CMS. (May 17, 2013). Revised appendix A, interpretive guidelines for hospitals, conditions of participation: Discharge planning. Gesme, D., Towle, E., & Wiseman, M. (2010). Essentials of staff development, and why you should care. Journal of Oncology Practice, 6(2), Graham, I., & Harrison, M. (2005). Evaluation and adaption of clinical practice guidelines. Evidenced Based Nursing, (8), October 12, Hill, K. (2014). AACN scope and standards for acute care clinical nurse specialist practice. Aliso Viego, California: American Association of Critical-Care Nurses. Hong, C., Abrams, M., & Ferris, T. (2014). Toward increased adoption of complex care management. The New England Journal of Medicine, 371(6), Kripalani, S., Roumie, C. L., Dalal, A. K., Cawthon, C., Businger, A., Eden, S. K., et al. (2012). Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: A randomized trial. Annals of Internal Medicine, 157(1), 1-10.

6 Lamb, G. (2013). Care coordination, quality, and nursing. In G. Lamb (Ed.), Care coordination: The game changer how nursing is revolutionizing quality care (First ed., pp. 1-3, 8). Silver Springs, Maryland: Nursebooks.org. Page 6 Marion, C. (Revised 2010). s of practice for case management (third Ed.). Little Rock, Arkansas: Case Management Society of America. McDonald, K., Schultz, E., Albin, I., Pineda, N., Lonhard, J., & Sundaram, C. (2010). Care coordination atlas version 3. Rockville, MD: Prepared by Stanford University. McHugh, M., & Lake, E. (2010). McHugh, M. D. and lake, E. T. [Understanding clinical expertise: Nurse Education, experience, and the hospital context] Res. Nurse. Health, (33), October, 12, McMahon, D., Certified Legal Nurse Consultant, retrieved from website, September Nursing s of Practice, National Quality Forum. (2006). NQF-endorsed definition and framework for measuring and reporting care coordination. Washington, DC: The Joint Commission. (2014). The 2015 Hospital Accreditation s. Oak Brook, Illinois: URAC, s interpretation as it relates to Case Management. Retrieved from website, October, 3,

7 CMSA of Practice for Case Management Crosswalk CMS Conditions of Participation-Interpretive Guidelines / 2013 TJC s-elements of Performance CMSA definition of case management: Case management is 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 cost effective outcomes (CMSA, 2009). CMSA CMS Joint Commission: Provision of Care, Treatment, and Services A (c) Identification of patients PC : Assessing patients needs for d/c in need of d/c planning and compliance with standard. A Client Selection Process for CM: The CM should identify and select clients who can benefit from CM services available in a particular practice setting. Documentation of consistent use of selection process within organizations policies and procedures. B. The CM should complete a health and psychosocial assessment, taking into account the cultural and linguistic needs of each client. Documentation of client assessments using standardized tools, when appropriate. C. Problem/Opportunity Identification The CM should identify problems or opportunities that would benefit from CM intervention. Documentation of agreement among the client, family, and other providers regarding the problems/opportunities identified. Documented identification of opportunities for intervention. D. Planning: The CM should identify short and long term needs, as well as develop appropriate CM strategies and goals to address those needs. Evaluate hospital s policy and procedure for D/C planning A D/C evaluation: The D/C planning evaluation must include D/C evaluation to patients identified in screening, patient s request, family request, and physician request. The hospital must include the D/C planning evaluation in the patient s medical record for use in establishing an appropriate D/C plan. A (b) D/C Planning evaluation: Evaluate Patient s care needs immediately on admission. Assess if they remain constant or decrease over time. Are they permanent or temporary? Is equipment or home modification necessary? Is the family willing and able to be trained to assume care? Can post-acute facility provide needed services? Cost and out of pocket expenses discussed with patient and family. In every unit with inpatient beds there is evidence of D/C planning and evaluation activities. A (b)(2) A RN, SW, or other qualified personnel must develop, or supervise development of the evaluation. Accepting the patient for care and treatment. PC Assessing and reassessing the patient Documentation of patient s need for care, treatment and service PC , PC : The hospital provides assessment and screening for all patients. The hospital assesses the patient who may be a victim of abuse and neglect. The hospital identifies any needs the patient may have for psycho-social or physical care, treatment, and services after D/C or transfer. Patients who receive treatment for emotional and behavioral disorders receive an assessment that includes a history of mental, emotional, behavioral, and substance use. Planning Care: PC , PC ; The provider delivers interventions based on the plan of care, including the education, or

8 Documentation of information using interviews and research to develop a plan of care. Recognition of client s diagnosis, prognosis, and care needs role in decision making, and outcome goals for plan of care. Validation plan of care is consistent with evidence based practice. Establishment of measurable goals, documentation of client s support system. Evidence of supplying the client with information and resources necessary to make informed decisions, awareness of maximization of client outcomes by all resources and services. Compliance with payer expectations with respect to how often to contact and reevaluate the client. E. Monitoring: The CM should employ ongoing assessment and documentation to measure the client s response to the plan of care. Documentation of ongoing collaboration with the client, family or caregiver, providers, and other pertinent stakeholders, so that the client s response to interventions is reviewed and incorporated into the plan of care. F. Outcomes: The CM should maximize the client s health, wellness, safety, adaptation and self-care through quality case management, client satisfaction, and costefficiency. Demonstration of the efficacy, quality, and cost-effectiveness of the CM s interventions in achieving the goals documented in the plan of care G. Termination of CM services: The CM should appropriately terminate cm services based upon case closure guideline. Review a sample of cases to determine if D/C planning evaluation was developed by a RN, SW, or other qualified personnel. A (b) D/C Planning Evaluation: The hospital must provide a D/C planning evaluation to the patients on their request or those requesting on behalf of patients. On every unit there is evidence of D/C planning activities. A (c) D/C Plan (1)- A RN, SW, or other appropriately qualified personnel must develop, or supervise the development of a d/c plan if the discharge planning evaluation indicates the need for a d/c plan. A sample of cases determine the d/c plan was developed by an RN, SW, or other qualified personnel, A (b): D/C Planning Evaluation The hospital must provide a d/c evaluation to the patients, the request of a person acting on the patient s behalf, or the request of the physician instruction of patients regarding their care, treatment, or services. Documentation of providing education, treatment, and services to the patient. PC The hospital D/C or transfers the patient based on his or her assessed needs and the organization s ability to meet those needs. Documentation demonstrating the patient s family licensed independent practitioners, physicians, clinical psychologists, and staff involved in the patient s care, treatment, and services participate in planning the patient s D/C or transfer. PC : The hospital provides interdisciplinary, collaborative care, treatment, and services Care, treatment, and services are provided to the patient in an interdisciplinary, collaborative manner. PC : the hospital has a process that addresses the patient s need for continuing care, treatment, and services after d/c or transfer.

9 Achievement of targeted outcomes or maximum benefit reached Change of health setting Client refuses further medical/psychosocial services Death of client H. Facilitation, coordination, and Collaboration The CM should facilitate coordination, communication, and collaboration with the client and other stakeholders in order to achieve goals and maximize positive client outcomes 483.3(e) Reassessment of d/c planning process on an ongoing basis. This must include a review of d/c plans to ensure that they are responsive to d/c needs. In every unit, is there evidence of d/c planning evaluation activities? A (c)(6)-comprehensive rule requiring list of SNF and HHAs provided to patients (c)(7) Inform patients of their right to choose the facility or service posthospitalization The hospital describes the reasons for and conditions under which the patient is d/c or transferred. The hospital describes the method for shifting responsibility for a patient s care from one clinician, hospital, program, or service to another. PC Coordination of Care is a major challenge in the safe delivery of care. The rise of chronic illness means that a patient s care, treatment, and services likely include an array of providers in a variety of health care settings, including the patient s home. Evidence of transitions of care, including: A transfer to the most appropriate health care provider/setting The transfer is appropriate, timely and complete Documentation of collaboration and communication with other health care professionals, especially during each transition to another level of care within or outside of the client s current setting Evidence of collaborative efforts to optimize client outcomes: working with community, local and state resources, PCP, other members of the health care team, the payer and other relevant health care stakeholders. 1.Qualifications for CM CM should maintain competence in their area of practice by having: Current, active, and unrestricted licensure or certification in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice of the discipline Assessment if patient s post-d/c care needs are being met in the environment from which he or she entered the hospital. What are the patient s needs immediately after d/c? What needs will lessen or worsen over time? Assessment of the patient s insurance coverage and how it may or may not provide for necessary services post-hospitalization. Assessment if patient can perform ADL prior to d/c. A (c)Discharge Plan A RN, SW, or other appropriately qualified personnel must develop, or supervise the development of, a d/c plan A (b)(2)-A RN, SW, or other appropriately qualified personnel must develop, or supervise the development of the evaluation The hospital has a process to receive or share patient information when the patient is referred to other internal or external providers of care, treatment, and services The process for hand-off communication provides for the opportunity for discussion between the giver and receiver of patient information The hospital coordinates the patient s care, treatment, and service for internal and external resources The PCP and the interdisciplinary team incorporate the patient s health literacy needs into the patient education. PC : The hospital provides interdisciplinary, collaborative care, treatment, and services

10 Baccalaureate or graduate degree in SW, nursing, or another health or human services field that promotes physical, psychosocial, and or vocational well-being of the person being served. The degree must be from an institution that is fully accredited by a nationally recognized educational accreditation organization and the individual must have completed a supervised field experience in CM, health, or behavioral health as part of the degree program Compliance with national and or local laws and regulations that apply to the jurisdictions and disciplines in which the CM practices Maintenance of competence through relevant and ongoing continuing education, study, and consultation Practicing within the CM s areas of expertise, making timely and appropriate referrals to and seeking consultation with, others when needed Determine which individual are responsible for developing or supervising the development of d/c plans. These should be an RN, SW, or other qualified personnel, supervised by them Care, treatment, and services are provided to the patient in an interdisciplinary, collaborative manner J. Legal The CM should adhere to applicable local, state, and federal laws, as well as employer policies, governing all aspects of CM practice, including client privacy and confidentiality rights. It is the responsibility of the CM to work within the scope of his/her licensure Compliance with national and or local laws and regulations that apply to the jurisdictions and disciplines in which the cm practices Maintenance of competence through relevant and ongoing continuing education, study, and consultation Practicing within the cm s areas of expertise, making timely and appropriate A (c): D/C Plan (1)- A RN, SW, or other appropriately qualified personnel must develop, or supervise the development of, a d/c plan if the d/c planning evaluation indicates a need for a d/c plan. Determine which individual are responsible for developing or supervising the development of d/c plans. These should be an RN, SW, or other qualified personnel, supervised by them PC : the hospital d/c or transfers the patient based on his or her assessed needs and the organization s ability to meet those needs. The patient, the patient s family, licensed independent practitioners, physicians, clinical psychologists, and staff involved in the patient s care, treatment, and services participate in planning the patient s d/c or transfer. Note 1: The definition of physician is the same as that used by CMS. Care, treatment, and services are provided to the patient in an interdisciplinary, collaborative manner

11 referrals to and seeking consultation with, others when needed How demonstrated J. 1. Confidentiality and Client Privacy The CM should adhere to applicable local, state, and federal laws, as well as employer policies, governing the client, client privacy, and confidentiality rights and act in a manner consistent with the client s best interest. Up-to-date knowledge of, and adherence to, applicable laws and regulations concerning confidentiality, privacy and protection of client medical information issues. Evidence of good faith effort to obtain the client s written acknowledgement that he/she has received notice of privacy rights and practices. J. 2 Consent for CM services The CM should obtain appropriate and informed client consent before CM services are implemented Privacy Act, 20 U.S.C. 1232g. Protected Health Information. The Privacy Rule protects all "individually identifiable health information" held or transmitted by a covered entity or its business associate, in any form or media, whether electronic, paper, or oral. The Privacy Rule calls this information "protected health information (PHI). Scrupulous protection of PHI during the referral process to Nursing facilities, Home health care agencies, and all outside referrals Secure permission from the patient or his or her representative to make these referrals. A (b)(1) The patient has the right to participate in the development and implementation of his or her plan of care ) The patient s rights should be provided and explained in a language or manner that the patient (or the patient s representative) can understand. In addition, according to the regulation at 42 CFR (b),(which cross references the regulation at 42 CFR ), each Medicare beneficiary who is an inpatient must be provided a standardized notice, An Important Message from Medicare (IM), within two days of admission. Medicare beneficiaries who have not been admitted (e.g., patients in observation status or receiving other care on an outpatient basis) are not required to receive the IM. The IM is a standardized, OMB-approved form and cannot be altered from its original format. The IM is to be signed and dated by the (RI , EPs 4, 5, and 7), and privacy of health information (IM , EPs 1 and 2) Taking steps to ensure that patient rights are respected, including communication, dignity, personal privacy Scrupulous protection of PHI during the referral process to Nursing facilities, Home health care agencies, and all outside referrals Secure permission from the patient or his or her representative to make these referrals. RI The hospital protects, promotes, and respects patient rights RI The hospital respects the patient's right to participate in decisions about his or her care, treatment, and services.

12 Evidence client and family were completely informed of: Proposed CM process and services relating to the client s health conditions and needs Possible benefits and costs of services Alternatives to proposed services Potential risks and consequences of the services and alternatives Client s right to refuse the proposed CM services and potential risks to refusal Evidence the information was communicated in a client-sensitive manner allowing the client to make choices K. Ethics CM should behave and practice ethically, adhering to the tenets of the code of ethics that underlies his/her professional credential (e.g. nursing, SW, rehab counseling, etc.). Awareness of the five basic ethical principles and how they are applied: Beneficence, non-malfeasance, autonomy, justice, and fidelity patient to acknowledge receipt. See Exhibit 16 for a copy of the IM. Furthermore, 42 CFR (b)(3) requires that hospitals present a copy of the IM in advance of the patient s discharge, but not more than two calendar days before the patient s discharge. In the case of short inpatient stays, however, where initial delivery of the IM is within two calendar days of the discharge, the second delivery of the IM is not required. The hospital must establish and implement policies and procedures that effectively ensure that patients and/or their representatives have the information necessary to exercise their rights This regulation requires the hospital to actively include the patient in the development, implementation and revision of his/her plan of care. It requires the hospital to plan the patient's care, with patient participation, to meet the patient's psychological and medical needs. The patient s (or patient s representatives, as allowed by State law) right to participate in the development and implementation of his or her plan of care includes at a minimum, the right to: participate in the development and implementation of his/her inpatient treatment/care plan, outpatient treatment/care plan, participate in the development and implementation of his/her discharge plan, and participate in the development and implementation of his/her pain management plan.

13 Recognition that a CM s primary obligation is to his/her clients Maintenance of respectful relationships with coworkers, employers, and other professionals. Recognition that laws, rules, policies, insurance benefits, and regulations are sometimes in conflict with ethical principles. CM is bound to address such conflict and seek appropriate consultation. L. Advocacy: The CM should advocate for the client at the service-delivery, benefitsadministration, and policy-making levels. Documentation demonstrating: Promotion of client s self-determination Education of health care and service providers in recognizing and respecting the needs, strengths, and goals of the client. Facilitation access to services and education about available resources Elimination of disparities due to race, religion, and all other possible discrimination. Advocacy for expansion or establishment of services and for client-centered changed in organizational governmental policy. Documentation indicates CM weighed decisions with the intent to uphold client advocacy vs. cost containment whenever possible. M. Cultural Competency: The CM should be aware of and responsive to cultural and demographic diversity of the population and specific client profiles. ICN October 2013 Your ability to communicate effectively with your patients will be more important as you help them understand and take action on health information. Effectively communicating during the encounter may result in Reduced patient anxiety during the encounter; Increased adherence to treatment protocols; More reports of patient satisfaction about encounters; Fewer medical malpractice lawsuits; and better patient health outcomes, such as EP 28 to RC The intent of this EP is to collect data in order to identify health care disparities, and hospitals have the flexibility to determine which categories of race and ethnicity are appropriate to their patient population.

14 How demonstrated CM understands relevant cultural information and communicates within the client s cultural contest Assessment of client linguistic needs and identifying resources to enhance proper communication. This may include the use of interpreters. increased quality of care and safety and reduced medical errors. Review the patient s medical history; Review the patient s language preference, belief systems, values, and lifestyle choices so that you can provide appropriate health care services; Recognize possible communication barriers; and Recognize that your culture, belief systems, and values may affect how you interact with patients. Allow extra time as the patient s primary language may not be English; Provide a professional interpreter as needed; Provide signage and educational materials that are written in language(s) of commonly encountered group(s) of the service area; Provide a list of agencies that can help with multi-cultural issues; and Learn about communicating with racially, ethnically, and culturally diverse patients. Joint Commission standards do not specify categories for the collection of race and ethnicity data, many state reporting entities and payors do specify these requirements. How demonstrated Resource Management and Stewardships The CM should integrate factors related to quality, safety, access, and evaluating resources for the client s care. Documentation of evaluating safety, effectiveness, cost, and potential outcomes when designing care plans to promote the ongoing care needs of the client. Evidence of follow through on care plans A (b): D/C Planning Evaluation The hospital must provide a d/c evaluation to the patients, on the request of a person acting on the patient s behalf, or the request of the physician 483.3(e) Reassessment of d/c planning process on an ongoing basis. This must include a review of d/c plans to ensure that they are responsive to d/c needs. In every unit, is there evidence of d/c planning evaluation activities? In every unit, is there evidence of d/c planning evaluation activities? PC Coordination of Care is a major challenge in the safe delivery of care. The rise of chronic illness means that a patient s care, treatment, and services likely include an array of providers in a variety of health care settings, including the patient s home. The hospital describes the reasons for and conditions under which the patient is d/c or transferred. The hospital describes the method for shifting responsibility for a patient s care from one

15 Evidence of utilizing evidence based guidelines, and guidelines specific to the CM s practice setting in making decisions about resource allocation and utilization Demonstration of linking the client with resources appropriate to the needs identified in the care plan. Fully informing the client of the length of time for which the resource is available, their financial responsibility, and the anticipated outcome of resource utilization. Documented communication of the client and other providers when there is a significant change in the client s condition, especially during transitions. Evidence of promoting the most effective and efficient use of hearth care resources and financial resources Documentation demonstrating that the intensity of cm services corresponds with the needs of the client Q. Research and Research Utilization The CM should maintain familiarity with current research findings and be able to apply them, as appropriate, in his/her practice Evidence of familiarization with current literature pertaining to the CM s expertise, and regular participation in appropriate training and/or conferences to maintain knowledge and skills. Compliance with legitimate and relevant research efforts, to quantify and define valid and reliable outcomes in CM Incorporation of meaningful research findings into practice as appropriate Agency for Health Care Research and Quality (AHRQ) AHRQ's mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with the U.S. Department of Health and Human Services (HHS) and other partners to make sure that the evidence is understood and used. CMs describe the revised Interpretive Guidelines for Hospitals, Cop: discharge Planning clinician, hospital, program, or service to another. Targeted Solutions Tool (TST) is an application developed by the Joint Commission Center for transforming Health Care to: Simplify the process for solving some of the most persistent health care quality and safety problems. Enhance the efforts already being made by Joint Commission-accredited health care organizations Facilitate the spread and use of the learning s from the Center s projects, including the identification of root causes and the targeted solutions that address causes of failures. CMs explain the purpose of the Joint Commission s Center for Transforming Healthcare CM s describe the initiative: Improving Transitions of Care: Hand-off Communications

16 Participation in identification of practical, hands-on approaches to CM best practice.