CASE MANAGEMENT HCP15 PROGRAM GUIDE FOR HEALTH CARE PROFESSIONALS

Transcription

1 HCP15 PROGRAM GUIDE FOR HEALTH CARE PROFESSIONALS National Educational Video, Inc. TM is an approved provider of continuing education. State Board provider numbers: Florida NCE2896, Alabama 5-97, California CEP8803, Kentucky and West Virginia WV RN. This activity provided by National Educational Video Inc. is approved as a provider of continuing education in nursing by Alabama State Nurses Association, which is accredited as an approver of continuing education in nursing by The American Nurses Credentialing Center's Commission on Accreditation. 1

2 HCP15 Case Management: Case management is the delivery of the right service at the right time in the right setting to maximize cost effective health care. Part 1 addresses components of case management, and models of case manager, as well as the role of the case manager. Part 2 examines tracking systems, such as critical pathways and case reviews, and two key processes in case management: utilization review and discharge planning. Video running time: 50 minutes. (3 contact hours) OBJECTIVES 1. Describe what Case Management is and why it is important in our current health care system. 2. Explain how case management benefits clients. 3. Describe different case management ideas/models and how the same are implemented in different settings. 4. Provide examples of case management. 5. Explain what proactive utilization management is. 6. Describe the process of discharge planning and the differences between health care settings. 2

3 The Nursing Process The nursing process is a systematic method of problem solving. It is based on the scientific method. The nursing process is called "process" because it is ongoing. These are the steps of the nursing process: Assessment: This is the systematic, ongoing collection of information from multiple sources. Assessment is done when a nurse interviews a client and the client s significant others. A physical assessment of the client is also completed observing the following: laboratory data, daily client actions, assessing the client s ability to carry out daily activities, symptoms and the client s response to treatment. In long term care, resident assessment instruments are used to provide a comprehensive multi-disciplinary assessment. Problem Identification or Nursing Diagnosis: Assessment data leads to identifying client strengths and client problems. These may be actual problems the client currently experiences, or potential problems that may occur with that client in the future. Problems are stated and related to a cause or influencing factor. Planning: The systematic steps that the nurse will enact, with others, to assist the client to meet the goals (or outcomes) that are set. For each problem, a measurable, specific goal is identified. The plan includes nursing actions, based on aspects of nursing theory, nursing science, other sciences, and research findings. The beliefs and values of the nursing profession as well as the values of the client are taken into account. Implementation: Carrying out the plan. Evaluation: This is the systematic process of examining each client goal-related outcome to determine if it were met and to revise the plan accordingly. Evaluation may also identify the resources that are needed for the client or the health care provider in their continuing plan of care. Professional Nursing Roles As the nurse carries out the nursing process, the nurse enacts a variety of professional roles. These are: clinician teacher client advocate leader These roles may overlap. In the clinician role, the nurse may provide direct "hands on" care, or may assess a client's needs and direct others to provide services to meet those needs. The nurse may conduct patient and family teaching in a teaching role. The nurse may also teach other health professionals when a multidisciplinary team addresses the client's needs. The nurse is a client advocate when collaborating with the client, finding resources for the client, and acting on behalf of the client. The nurse is a leader when planning and assigning the care of a client to others, maintaining overall responsibility and accountability for that care, assisting other members of the health care team to set and meet goals or when providing resources to other health care providers. 3

4 GLOSSARY OF KEY TERMS Case management: While there are many definitions, a working definition of case management for this program uses five features: (1) it is a collaborative process with multiple health care providers; (2) assessment and planning, implementing, and monitoring care; (3) uses available resources to promote quality, cost effective outcomes. (4) views health care as a connected continuum of services and (5) enacts managed care, whereby financing and service delivery are continuously tracked and evaluated. Continuum of Care: Care provided in a continuous series of health care settings, i.e., hospital to long-term care facility, to home, to outpatient clinic, etc. Discharge Planning: The activities that facilitate a client s movement from one health setting to another. It is a multidisciplinary process involving physicians, nurses, social workers, and possibly other health professionals and its goal is to enhance continuity of care. Managed care: A system of delivering health care in which an organization promises to provide quality, cost effective health care to a subscribing company s members, usually employees and their families. The subscribing company pays the organization a set fee per person per month. The organization makes arrangements with health care providers. This arrangement may be a capitated arrangement, in which the provider agrees to accept a set fee per person per month. Or it may be a discounted fee-for-service arrangement. Cost of services, utilization of services, and performance measures are continuously evaluated. Prospective Reimbursement (Payment System): A method of payment to an agency for health care services to be delivered based on predictions of what the agency s costs will be for the coming year. Utilization Review or Utilization Management is a process whereby a trained reviewer monitors the use of services to provide health care to a client. 4

5 SUPPLEMENTAL HAND OUT What is Case Management? In order to understand Case Management, it is important to understand the basics of Managed Care which is the foundation for Case Management. Often the terms Managed Care and Case Management are used interchangeably. But as the following information will clarify, the two have related yet different meanings. Managed Care has been a megatrend in health care, developing in response to escalating health care costs and defined as A system that integrates the financing and delivery of appropriate health care services to covered individuals. (Health Insurance Association of America) This definition includes all settings of health care: acute care hospitals, long term care facilities, home care, etc. Common elements of Managed Care are: arrangements with selected providers to furnish a comprehensive set of health care services to members explicit standards for the selection of Health Care providers formal programs for ongoing Quality Assurance and Utilization Review significant financial incentive for members to use providers and procedures covered by the plan In contrast, defining Case Management is not an easy task. There is a wide range of definitions currently circulating which include the following language: clinical production process, purposeful and controlled connections between the quality of care and the costs of that care, a process of service coordination, a set of logical steps and a collaborative process. A formal definition of Case Management that includes these ideas is: Case Management is a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates options and services to meet an individual s health needs through communications and available resources to promote quality, cost effective outcomes. (Case Management Society of America) Case Management is a process that provides continuity of provider by linking people across clinical settings. The process attempts to connect previously unconnected parts of the health care system to form a continuum of care. The concept of continuum of care has gained importance with the ongoing development of Case Management and has been emphasized by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). JCAHO has revised its standards to reflect a separate chapter dedicated to the continuum of care process. The Case Management process provides a set of methodologies and systems that ensures the attainment of the product -- the best outcomes possible for the patient and significant other(s). What is critical to remember is that Case Management can be implemented in a variety of ways in a variety of settings. Generally, the institution, agency and/or service which elects to implement a Case Management program examines the services provided, population served, resources available and other specific characteristics in order to develop a program which 5

6 SUPPLEMENTAL HAND OUT (Continued) would promote the best quality outcome while concurrently demonstrating efficient utilization of services. The process combines a business approach with clinical care management. Case management programs are developed to provide case oversight which will ensure that the client receives the best quality service, in the appropriate setting, with the most effective management of resources. Some examples of the various types of programs include: 1) insurance company case management programs which are most often staffed by nurses; these nurses conduct either telephonic case review and/or on-site case review which includes benefit verification, utilization management, discharge planning and general case oversight; this oversight includes reviewing all aspects of a case to insure that there are no redundancies and to insure that all services provided remain consistent; 2) acute care hospital case management programs; these include any combination of utilization management, discharge planning, infection control, social services and/or quality improvement services. Some hospital programs even include medical record services. These types of programs are often staffed by a complement of clinical and support staff with the clinicians providing case oversight; 3) home care agency and/or community social service agency case management services often include a nurse and/or social worker providing case oversight. Regardless of the model developed, there are common threads basic to all models. These include the following: A client focused approach: The care provider considers the client s perception and desires when assisting with planning and arranging care. Also included is involvement of the client s family and/or significant other(s). Specific client perceptions and/or desires can range from something simple such as a dietary preference to a more complex issue such as adherence to a cultural/religious practice. For example, in some cultures men are not permitted to provide physical care for women. In such cases, the provider would need to consider appropriate support systems for a female client requiring personal care and/or dressing changes. Specific Role Identification: The provider may have many different titles (case coordinator, case manager, etc.). The role of the provider requires specific definition in order to avoid confusion for the client and to ensure that all needs are met. This role is often expanded from the traditional nurse, case worker, and/or social worker, etc. In addition, the role of the entire health care team requires definition to provide the most quality focused services both collaboratively and individually. Examples include: 6

7 SUPPLEMENTAL HAND OUT (Continued) Clarifying the exact individual who will provide team leadership in terms of case organization, i.e., the nurse, social worker versus which individual(s) will provide hands-on care; clarifying the exact responsibilities and/or tasks of each team member to avoid overlap/redundancy, i.e., the physician and primary nurse provide patient education, the social worker attends to psychosocial needs and financial issues. Role identification and clarification sound very simple but often are not when introducing a new Case Management program. Individual disciplines may be territorial and resent initiation of the new, expanded role of the provider. This issue is manageable with foresight, planning and education. Collaborative Practice: The health care team is multidisciplinary and may include: physicians, nurses, therapists, dietitians, social services, client, family/significant other(s) and any other ancillary staff required. The process of case management brings all of these disciplines together, collaborating to provide care for the client in the most efficient manner. It is imperative that all members of the team participate actively in order to produce a positive, comprehensive outcome. Collaborative practice includes family meetings which all aspects of the client s care can be discussed, education provided and problems solved. Often during family meetings, members of the multidisciplinary team take turns explaining the aspect of care for which they are responsible as well as progress toward objectives. The implementation of a Tracking System is the key to the success of any Case Management program. With any program, the outcomes must be monitored and tracked to determine ongoing effectiveness. Practice patterns may be adjusted to promote improved client care outcomes. Often money is the element tracked; however, with the ongoing development of Case Management, more attention is focused on the actual provision of service, practice patterns, utilization of resources, time frames, and outcomes to determine effectiveness. If these elements are managed properly and effectively, the financial impact corresponds positively. Tracking systems can be implemented concurrently (while the patient is actually receiving services/care) and/or retrospectively (after the services/care have been provided) to monitor general case management, i.e., each case is monitored based upon a local or national standard of practice. For example, a metropolitan hospital/facility/agency may serve one client population with specific primary health care issues (i.e., HIV, TB and/or substance abuse) whereas a small, rural community hospital may serve a different client population with entirely different primary health issues (i.e., increased number of elderly living alone with limited support systems as children migrated toward metropolitan areas). Based upon the variety of client populations, available resources per geographic area as well as a large number of other variables, cases must be monitored consistent with the variables. 7

8 SUPPLEMENTAL HAND OUT (Continued) With any system of tracking, there must be a corresponding method of documenting the data. This is often referred to as Variance Analysis. Variance analysis is detailed documentation, review and interpretation of data. It is often an arduous process. All data must be reviewed carefully and decisions made relative to which data is considered pertinent when making program changes. For example, client responses and/or family cooperativeness may be impossible to control. Whereas the selection of community provider, treatment regimen, use of resources, availability of funding may be more in control. Outcomes and variances can be monitored via a variety of tracking systems but one of the most basic is simple case review. For example, the provider may review the case of a client who has undergone a total hip replacement. There are expected standards of care for this procedure which may include specific times when physical therapy and/or medication is to be initiated post operatively. Should care provided not adhere to the standard, the provider would evaluate the reason for same and determine any related outcomes. Simply stated, the client did not receive PT for three days post operatively (due to low staffing in the Department) and the same should have begun on the first post operative day. As a result, the client was not properly mobilized and developed a deep vein thrombosis requiring heparin therapy and an extended length of stay, all of which cost the provider institution significant additional expense. In summary, successful Case Management programs do not occur overnight. They require careful planning, data review, education, resource review and allocation, all of which can take weeks, even months to complete. Implementation also takes time and patience. Even with significant education and common use throughout the nation, there is often resistance. Once implemented, the program requires serious review; a valuable Quality Improvement Plan is the key to the success of any Case Management program. This plan must include performance measures such as standards of practice (i.e., critical pathways), financial (i.e., expected cost to provider agency and corresponding final cost) and outcome indicators (i.e., actual client outcomes related to anticipated outcomes) to name a few. A Quality Improvement Plan should be documented prior to initiation of a program. However, the same must be reviewed and revised regularly to insure that performance measures are reasonable and attainable. UTILIZATION REVIEW Utilization Review, more currently referred to as Utilization Management, is a process whereby a trained reviewer monitors the use of services to provide health care to a client. Usually, the reviewer is a clinical professional and, more often than not, this is a nurse. Whether the nurse is an LPN or an RN, the nursing professional brings a wealth of clinical knowledge and expertise to the role. Generally, any other health care provider such as a social worker, would not be able to review, monitor and make recommendations relative to the clinical aspects of the cases. 8

9 SUPPLEMENTAL HAND OUT (Continued) Utilization Management is common in hospital-based care but is also prevalent in outpatient settings. In addition, insurance carriers generally maintain a staff of professionals who monitor utilization of services for their clients who receive services. Simply, a professional concurrently monitors the care provided to a client, while the patient is actually receiving services/care. They ensure that the service is provided timely, efficiently, in the proper setting, by the appropriate care providers relative to the client s needs and in a quality manner. In essence, the purpose of Utilization Management is to ensure, promote and facilitate efficient care in a timely manner while maintaining high quality standards. For example, an insurance based case manager would follow up on a client discharged from an acute care setting to home with home care. The case manager would contact both the patient and the home care provider to ascertain whether the required services were initiated on a timely basis, how long the services will be provided and the client s response to same. If the client is not within expectations, the case manager would collaborate with the home care provider for a revised plan of care. Utilization Management generally occurs on a concurrent basis, that is, once it is known that care has been initiated the reviewer confirms that the initial care plan is appropriate for the client s identified needs. Subsequently, the reviewer monitors the care plan to ensure that ongoing care is reflective of appropriate utilization of services. This is often the method of conducting utilization management within the hospital inpatient setting. However, a review of utilization of services is also conducted within outpatient settings (such as home care agencies) and community based facilities (such as nursing homes). Home care agencies and nursing homes receive referrals from hospitals, community clients and/or health care providers. Prior to accepting clients for service, evaluations are completed. These include a detailed review of client needs and planned care. This allows the community provider to determine if the capability to provide the required care, is available. Should it be determined that the client requires a different level of care, the client would probably not be accepted into the referred service and would be referred elsewhere. Proactive utilization management means that the reviewer is knowledgeable regarding management of a specific patient population(s). Some patient populations are surgical, medical, psychiatric, general hospital. The reviewer is knowledgeable of customary treatment regimes and expected progress. Thus, the reviewer is able to anticipate any potential/actual complications which may hinder efficient management and positive outcomes and take actions to prevent complications. The role of the case manager has become increasingly important throughout the last decade. In response to changes within Federal and State governed reimbursement systems, case managers have become integral members of the health care team. These professionals have expertise in both the financial and clinical management of clients and therefore are able to view cases from a more general perspective. 9

10 SUPPLEMENTAL HAND OUT (Continued) Some history about the Federal and State changes follow: Conducting utilization management became prominent in the early 1980s with the advent of the Prospective Payment System. Prior to that time, hospitals and outpatient setting providers were reimbursed for client care based upon the actual cost. However, health care costs accelerated drastically from 1950 with 4.1% of the Gross National Product (GNP) to 10.5% of the GNP in Due to these extreme accelerations, the Federal Government developed the PPS which reimbursed hospitals based upon a predetermined or fixed rate for each diagnosis. In developing these rates, consideration was given to the principal diagnosis, disease process, client age and complications which would be common to the diagnosis. Consideration was also given to the location and type of hospitals such as whether or not the hospital was metropolitan or urban and whether or not it was teaching. Initially the PPS was effective for all Medicare recipients. However, numerous states adopted a similar system for non-medicare recipients. The PPS also allowed for certain exclusions such as psychiatric, rehabilitation, pediatric and cancer hospitals/units. However, currently most insurances reimburse in the same or similar manner for all services. In addition, outpatient providers, including physicians, are now reimbursed under similar systems which preclude full retrospective payment. The PPS was obviously instituted to control health care costs. But hospitals were forced to seriously evaluate their utilization and provision of services for improvements in efficiency and effectiveness. These improvements would decrease cost while maintaining and/or improving quality. DISCHARGE PLANNING Discharge planning is the process by which a professional assists clients with arranging and securing services necessary for continuation of care after a segment of service is complete. For example, when a hospital inpatient has completed an inpatient stay, it is often necessary to provide follow-up care in the home and/or within a community based facility such as a nursing home. An elderly home care client may no longer require extensive home follow up but might benefit from referral to a senior center for daily visits and activities. A nursing home client may have recovered and can subsequently return home with family and home care. In today s health care arena, discharge planning has become increasingly important due to the current trends with regard to decreased lengths of inpatient hospital stays, decreased length of stay in long-term care facilities, increased use of outpatient community services, increased regulation on health care by insurance carriers and often decreased and/or unavailability of services within the community. 10

11 SUPPLEMENTAL HAND OUT (Continued) EXAMPLE: A 55-year-old female with degenerative joint disease is scheduled for a total hip replacement by her primary orthopedic surgeon. The surgeon s office contacts the client s insurance company to verify inpatient and physician benefits. Subsequently, the office schedules the procedure with the hospital. The client is instructed to attend a routine pre-surgical screening at the hospital where bloodwork, EKG, anesthesia interview, etc., are completed. On the same day, the client attends an educational session specific for total joint replacement clients. The session is conducted jointly by a nurse and a case manager. A social worker is also available via referral to discuss any social issues (ranging from financial hardship to potential substance abuse issues) which might be present. The nurse explains the preparation and recovery phase of the procedure, including medications, therapies, breathing exercises, immediate post-operative recovery, etc. The case manager explains the process of utilization review, including regular contact with the insurance company to determine ongoing benefits; the case manager will also contact the insurance company for verification of benefits for inpatient length of stay and outpatient aftercare services. The case manager explains the discharge planning process including various types of options to include, but not limited to: home independent, home with services, short stay in a sub-acute care setting, short stay in an intense rehabilitation setting, long stay in a long-term nursing home. For each of these options, the case manager may provide a list of available agencies/facilities/services. In addition, the case manager may discuss potential equipment needs and resources for same, including commodes, hospital beds, walkers, canes, etc. It is during this pre-screening that initial questions are answered and discharge planning is initiated. Although the client may be admitted several days later, the process has been initiated prior to actual entry to the setting. After admission, the case manager follows the case to determine ongoing appropriate utilization of inpatient services and assists the client with final determination and implementation of aftercare plans. Once the client determines a discharge plan that is mutually agreed to be safe and appropriate, the case manager, if necessary, completes the corresponding referrals to the community-based providers selected by the client. The home care agency and/or short or long term facility representatives will assess the client for appropriateness of entry to the service. This assessment includes evaluating the client needs, the agency/facility ability to provide same and the financial resources for same. 11

12 SUPPLEMENTAL HAND OUT (Continued) The entire health care team would participate in the client s overall care, physician, nurse, case manager, therapists, social workers, dietitians, etc. and would complete their individual activities as well as collaborate in team meetings. The physician would provide medical management of the case including all orders for plan of care, medications, testing, aftercare services, etc. The nurse and/or technicians would provide daily personal care, treatments, client education, medication administration, monitoring of plan of care and progress. The therapists would provide and monitor services specific to their individual area of expertise (i.e., physical, occupational, speech, psychosocial). Dietitians would obviously monitor the client s nutritional care/concerns, provide related education and recommendations. The social worker would address the psychosocial concerns of the client, including support system/family issues and provide recommendations regarding same. If trained, the social worker may also provide individual and/or group therapy sessions as needed. The case manager role has previously been explained. The plan is finalized concurrent with a client s stay in the acute setting and efficient discharge to the aftercare provider. The case can be tracked utilizing a Critical Pathway or Care Map, both of which would define the expected standard of care for a client with this type of procedure. The outcomes will be reviewed and measured against the standards with individual characteristics considered. Variances would be reviewed to determine if the same were reasonable for the individual and/or if a standard of care was not met which ultimately resulted in the variance. Utilizing this data, standards are re-evaluated and changed on a regular basis. Case Management pictures health care as a continuum, as a connected set of services. These can be represented as a line, with related services: Wellness & Prevention Illness/injury Treatment Rehabilitation exercise diet relaxation stress management safe work habits sleep seat belt use safe sex habits immunizations screening smoking cessation crime prevention risk management annual physicals infection illness injury disability trauma medication surgery therapies therapeutic diet radiation therapy therapies maintenance orthotic 12

13 SUPPLEMENTAL HAND OUT (Continued) Case management is the linkage of services across this continuum. Some case managers may manage only a particular episode or time segment. Other case managers may manage care across a more extended time period. The concept of continuum is integral to Case Management and is emphasized by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). 13

14 PRE TEST PART 1 Circle T if the following statements are true. Circle F if the following statements are false. T F 1. Case management is applicable only in home settings. T F 2. Case management arose out of a need to contain spiraling health care costs. T F 3. Case management only monitors financial expenditures. T F 4. Collaboration is only needed when the case manager is not a nurse. T F 5. Length of stay and readmission rates are types of outcomes monitored by case managers. T F 6. Managed care is the same as case management. T F 7. The continuum of services concept in case management is used to treat different types of health care services as separate and distinct. T F 8. Insurance case management models monitor the client s utilization of services across multiple settings. T F 9. Hospital case managers initiate discharge planning only when the client is showing progress after surgery or medical treatment. T F 10. Case management focuses only on the evaluation of services, and the cost of services, that have been provided. 14

15 DISCUSSION QUESTIONS/SHORT ANSWER ESSAY 1. What is Managed Care and how has this megatrend impacted health care today? What impacts have you experienced directly in your current work? 2. Have you experienced case management in any form on your current job? If so, how? If not, do you believe case management has a place in your current work environment? 3. Are you familiar with the concept of case management in settings other than your current work environment? 4. Should a case management process be a mandatory part of every health insurance plan? If so, why? If not, why not? 5. Have you actively participated in any type of collaborative practice? 6. What types of discharge planning activities have you experienced? 15

16 POST TEST PART 1 Circle the letter of the response that best answers the question. 1. Societal factors that contribute to the development of management models in the 1990 s include: a. longer length of stays in hospitals b. longer length of stays in long term care centers c. increased use of community-based resources d. all of the above 2. Managed care is best described as: a. another name for case management b. a method of providing health care services that emphasizes quality, cost effective services c. a means of documenting care from many providers d. collaborating with many different types of health care professionals 3. Collaboration is one component of case management. Collaboration requires: a. clear definition of roles of the case manager and the health care team members b. that one person be in charge and direct all other members of the health team c. that different disciplines focus only on their own specialty d. that each discipline establishes its territory and defends it 4. The continuum of services concept is a means of visualizing a. connections between health care providers b. connections between health care services c. an unbroken line of communication among health care providers regarding a single client d. all of the above 5. In case management, the health care team collaborates on: a. evaluating outcomes only b. measuring length of stay and readmission rates c. assessing, planning, implementing and evaluating care d. discharge planning only 6. The role of the case manager is expanded from the traditional role, whether the position is filled by a nurse, social worker or other health care professional. What is added to the traditional role? a. accountability for clinical outcomes b. accountability for clinical and financial outcomes c. responsibility for the client for an extended time period d. all of the above 16

17 POST TEST PART 1 (Continued) 7. To evaluate whether or not utilization of services is effective, the case manager must examine: a. financial, clinical, patient satisfaction outcomes, length of stay and readmission rates b. readmission rates and length of stay only c. credentials of the health care providers d. standards of care and clinical outcomes 8. In case management, clinical outcomes are measured by comparing them with: a. each individual client s own progress b. a standard that is set for the average person with the same type of health problem c. financial expenditure d. whether or not they were provided in the appropriate setting 9. When case managers are not nurses, it is important that they; a. use their own clinical expertise to evaluate nursing care b. direct the interdisciplinary health care team c. collaborate with nurses and other clinical health care professionals for assessing, planning, implementing and evaluating care d. use published standards for nursing input on specific client cases 10. When case management of a client includes home care services, home health nurses may interact with: a. the hospital case manager when the client is to be discharged from the hospital to home b. the insurance case manager when the client s services are covered by insurance c. the long term care case manager when the client is to be discharged from the long term center to home d. all of the above 17

18 PRE TEST PART 2 Circle T if the following statements are true. Circle F if the following statements are false. T F 1. Tracking systems must include clinical outcomes. T F 2. A case study review is a type of tracking system. T F 3. Tracking system tools may be included as part of the client s permanent record. T F 4. Tracking systems are designed based on the average patient with a particular health problem. T F 5. Discharge planning is initiated when a client has completed a set of health care services. T F 6. Utilization review may be proactive, meaning looking ahead to anticipate and prevent problems. T F 7. Nurses and other clinical health professionals should rely on a tracking system to direct and guide their clinical judgment. T F 8. All members of the interdisciplinary team are responsible for utilization review. T F 9. Clinical pathways are effective with clients with multiple diagnoses. T F 10. A clinical pathway always addresses a client s entire set of health care needs across multiple settings. 18

19 NATIONAL EDUCATION VIDEO, INC. TM DISCUSSION QUESTIONS/SHORT ANSWER ESSAY PART 2 1. What components must be included in any tracking system? How are these used? 2. Explain the utilization review process. 19

20 POST TEST PART 2 Circle the response that best answers the question. 1. A home health agency case management model: a. uses discharge planning and utilization review b. does not use any of the same processes as an insurance case management model c. is only nursing focused d. all of the above 2. Which of the following is/are tracking systems? a. critical pathways b. case review c. case study review d. all of the above 3. Clinical outcomes in a tracking system must be: a. pertinent to all clients of a given age group b. measurable c. based on an individual nurse s experience d. all of the above 4. When a client does not meet an expected outcome on a clinical pathway, it is important to first: a. revise the plan of action b. revise the expected outcome c. assess why the client did not meet that outcome d. collaborate with the team 5. Discharge planning should be initiated: a. by the client and family member b. upon admission to services c. when steady progress toward desired outcome is seen d. when clients exceed the average length of stay 20

21 POST TEST PART 2 (Continued) 6. When discharge planning, the nurse needs to ask which of the following questions? a. what knowledge does the client need to have? b. what skills does the client need to learn? c. what resources does the client need? d. all of the above 7. When the client has a family member or significant other, the nurse needs to: a. include the family member in discharge planning after the nurse assesses the client b. include the family member in discharge planning after the health care team develops a plan of care for the client c. determine the client s needs before talking with the family member d. include the family member in discharge planning when the client is first admitted for services 8. When discharging a client to a home setting, the case manager needs to: a. assure that discharge is appropriate b. assure that discharge is as soon as possible c. wait until the client is home, then arrange for services d. all of the above 9. Discharge occurs: a. to home settings b. to long term care facilities c. to community based facilities d. to all of the above 10. Which groups benefit from case management? a. nurses b. clients c. physicians and other health care providers. d. all of the above 21

22 ANSWER SHEET PRE TEST PART I PART 2 1. F 1. T 2. T 2. T 3. F 3. T 4. F 4. T 5. T 5. F 6. T 6. T 7. F 7. F 8. T 8. F 9. F 9. T 10. F 10. T POST TEST PART I PART 2 1. d 1. a 2. b 2. d 3. a 3. b 4. c 4. c 5. c 5. b 6. b 6. d 7. a 7. d 8. b 8. a 9. c 9. d 10. d 10. d 22

23 REFERENCES Birmingham, J. (1994). Discharge Planning for Case Managers: The Process of Continuity of Care. Los Angeles, CA. Case Management Society of America. Washington, D.C. Centers for Disease Control and Prevention (1995) Prevention and managed care: Opportunities for managed care organizations, purchasers of health care, and public health agencies. Morbidity and Mortality Weekly Report. 44 (No,.RR-14): Corbett, C.F. and Androwich, I.M. (1994) Critical paths: Implications for improving practice. Home Healthcare Nurse. 12 (6): Dodd, K. and Coleman, J.R. (1994) Home care and managed care: Prospective partners. Caring Magazine. XIII (3): Esposito, L. (1994) Home health case management. Home Healthcare Nurse. 12 (3): Fondiller, S. H. (1991). How Case Management is Changing the Picture. American Journal of Nursing, (10), Giuliano, K. K. and Poirier, C. E. (1991). Nursing Case Management: Critical Pathways to Desirable Outcomes. Nursing Management, 22(3), Howe, R. S. (Editor). (1994). Case Management for Healthcare Professionals. Chicago, Illinois. Hydo, B. (1995) Designing an effective clinical pathway for stroke. American Journal of Nursing. 95 (3): Koch, M.W. (1995) Hope with Hospice: AIDS Case Management. Continuing Care. 14 (8): 32-34, 36. Molloy, S.P. (1994) Defining case management. Home Healthcare Nurse. 12 (3): (November 1994) Risk, relationships, revenue: Understanding the three R s of managed care. Homecare Administrative Horizons. 1 (1): p. 1,8 Rozell, B.R. and Newman, K.L. (1994) Extending a critical path for patients who are ventilator dependent. Home Healthcare Nurse. 12 (4): Salmond, S. W. (1990). In-Hospital Case Management. Orthopedic Nursing, 9(1) (Continued) Schauffler, H.H. and Rodriguez, T. (1993) Managed care for preventive services: A review of policy options. Medical Care Review. 50:2:

24 REFERENCES Source Book of Health Insurance Data. (1992). Health Insurance Association of America. Washington, D.C. St. Anthony s DRG Working Guidebook. (1994). St. Anthony s Publishing. Zander, K., ed. (1994) Case management series part I: Rationale for care-provider organ-izations. The New Definition. 9 (3): 1-2. Zander, K., ed. (1995) Case management series part III: Case manager role dimensions. The New Definition. 10 (1): 1-2. While NEVCO strives to remain current with federal and state regulatory requirements, the information contained in this video presentation is always subject to governmental amendment. Therefore, we suggest that you contact your state and federal authorities for any possible revisions to this material. 24

25 RESOURCE ADVISOR Nancy Magliocca, RN, BSN, MS, was a resource advisor for HCP15. She is certified with the American Board of Quality assurance and Utilization Review. Ms. Magliocca accepted the role of Director of Case Management within a Connecticut-based acute care hospital in In this role, she has been responsible for daily leadership of the function to include utilization review, discharge planning and social work services. This leadership has involved providing direction and education to a complement of nurses, social workers and support staff. In 1995, Ms. Magliocca assumed additional management responsibility for the setting s Quality Improvement and Infection Control Departments and for the HIV Program Coordinator. Through this most recent experience, Ms. Magliocca has been actively involved in the structuring and formalization of the Case Management Department and creative planning for same. She currently remains in her role within the Connecticut-based hospital and continues to expand her knowledge base via a variety of nationally offered educational programs. NEVCO video educational programs are prepared using specific criteria designed by National Educational Video, Inc. All educational programs are coordinated and reviewed under the direction of the NEVCO Director of Education, who is a master s prepared nurse. 25

26 Participant Evaluation of Objectives Please evaluate this program by circling the number that best represents how well this program met the following objectives: 4=Excellent 3=Good 2=Average 1=Poor 1. Describe what Case Management is and why it is important in our current health care systems Explain how Case Management Benefits clients Described different Case Management ideas/models and how the same are implemented in different settings Provide examples of Case Management Explain what proactive Utilization Management is Describe the process of Discharge Planning and the difference between health care settings Do you feel you met your personal objectives? Time required to complete this program? minutes COMMENTS: Return this form with the Participant Evaluation to your facilitator who distributed this learning material. Thank You. 26

27 NEVCO Account # REQUEST FOR CERTIFICATES FOR CONTACT HOURS TYPE the NAMES, LICENSE NUMBERS AND JOB TITLES (RN, LPN, MSW, CNA, PT, etc.) of the people who are to be issued a certificate for contact hours for attending the continuing education program: (Facility Name) (Title and Number of Video Program) This request must be submitted along with the completed roster and evaluation sheets for the above named program NAME LICENSE NO. JOB TITLE

28 Must be completed by the facilitator EVALUATION OBJECTIVES: TIB Bank Center th Street N., Suite 207 Naples, Florida (800) Fax (888) FACILITATOR S EVALUATION (NEVCO Video Education Program) (1) To assess extent to which the program was appropriate, adequate and effective. (2) To identify, continue to develop and evaluate effective quality assurance activities. Title of Program Date Place of Employment Job Title Please evaluate the presentation by circling the number that best describes your rating. 4 Excellent 3 Good 2 Average 1 Poor ORGANIZATION OF COURSE Material was organized to facilitate learning The amount of material covered was adequate and accurate There was effective use of time to cover the subject CONTENT OF THE FACILITATOR S GUIDE List total number of objectives in this facilitator s guide List by number the objectives that were met The test material reflected the objectives listed Content can be used to improve nursing practice Content reflected knowledge level and needs of learner The material was current Evaluate Test Questions Pre-Test Discussion Questions Post-Test FACULTY PRESENTING (Video) The presentation was The presenter explained the material The presenter demonstrated knowledge of material OVERALL RATING I felt this teaching method was COMMENTS (Please make suggestions for future topics and additional comments about the presentation or instructor) Thank you for your time in completing this evaluation! We appreciate your comments and suggestions. The NEVCO Educational Staff 1995 Revised 10/2004

29 EVALUATION (NEVCO Video Education Program) TIB Bank Center th Street N., Suite 207 Naples, FL (800) Fax (888) Must be completed by every participant EVALUATION OBJECTIVES: (1) To assess extent to which the program was appropriate, adequate and effective. (2) To identify, continue to develop and evaluate effective quality assurance activities. Title of Program Date Place of Employment Job Title OBJECTIVES Total number of objectives in program Circle the number of objectives that WERE met Circle the number of objectives that were NOT met Please evaluate the presentation by circling the number that best describes your rating. 4 Excellent 3 Good 2 Average 1 Poor ORGANIZATION OF COURSE Material was organized to facilitate learning The amount of material covered was adequate and accurate CONTENT OF THE PRESENTATION The test material reflected the objectives listed Content and/or skills demonstrated can improve my ability to perform my job Content reflected knowledge level and needs of learner The material was current Time for questions was Effective use of time to cover subject was Graphics were beneficial NEVCO FACULTY (who prepared the program and/or appeared in interviews) The presentation was well prepared The presentation explained the material well The presenter demonstrated knowledge of material OVERALL RATING I felt this teaching method was Facilities and classroom were adequate COMMENTS (Please make suggestions for future topics, content of program and instructors) Thank you for your time in completing this evaluation! We appreciate your comments and suggestions. The NEVCO Educational Staff 1995 Revised 10/2004

30 TIB Bank Center th. Street N., Suite 207 Naples, FL (800) Fax: (888) CONTINUING EDUCATION ROSTER This form must be completed and returned to NEVCO. Keep a copy for your facility, but return the original to NEVCO. PRINT OR TYPE Account # Number and title of Video Program Dates Given Contact Hours Name of Facility Address of Facility City/State/Zip RN Facilitator Signature ROSTER OF PARTICIPANTS Participant Name Participant Signature License # Soc. Sec. # National Educational Video, Inc. TM is an approved provider of continuing education. State Board provider numbers: Florida NCE2896, Alabama , California CEP8803 and Kentucky This activity provided by National Educational Video Inc. is approved as a provider of continuing education in nursing by Alabama State Nurses Association, which is accredited as an approver of continuing education in nursing by The American Nurses Credentialing Center's Commission on Accreditation.

31 Participant Name Participant Signature License # Soc. Sec. #

32 599 9 th Street N., Suite Naples, FL Fax: Certificate of Completion This is to certify that Attended and Completed National Educational Video, Inc. TM Program Number and Title For contact hours On Date Facility / Agency Name Facility / Agency Address RN / Facilitator CERTIFICATE FOR ASSISTANTS ONLY National Educational Video, Inc.TM is an approved provider of continuing education. State Board provider numbers: Florida NCE2896, Alabama , California CEP8803 and Kentucky This activity provided by National Educational Video Inc. is approved as a provider of continuing education in nursing by Alabama State Nurses Association, which is accredited as an approver of continuing education in nursing by The American Nurses Credentialing Center's Commission on Accreditation.

33 CERTIFICATE OF COMPLETION For each participant who has successfully completed a continuing education program, please make a copy of the blank NEVCO Certificate (on reverse side) and fill in the following information: 1. Name of the learner 2. Program title and number 3. Number of contact hours 4. Date the program was completed 5. Name and address of your Agency / Facility 6. Signature of the RN / Facilitator responsible for offering the program