Managed care refers to health insurance systems in which insurance companies create contracts with service providers to offer services at reduced costs. Because of this, one scenario in which managed care constitutes a viable solution is the family’s need for high-cost interventions, such as surgical oncology services for a child. In this case, the use of managed care solutions, for instance, preferred provider organizations (PPOs), provides multiple benefits for the family linked with costs, quality, freedom of choice, and convenience (Dohmen & Van Raaij, 2019). The speed of patient information flow within managed care networks is another prominent advantage to supporting the family’s well-being and ensuring the development of comprehensive post-surgery treatment plans (Dohmen & Van Raaij, 2019). Using managed healthcare and PPO plans, the family is granted the right to choose from a network of providers, which supports the right balance between services’ financial accessibility and quality. Another beneficial characteristic is the opportunity to reduce transportation costs and enable the parents to emotionally support their child by selecting the best possible provider near their place of residence.
Case management, a specific managed care technique, is a collaborative referral, care planning, evaluation, and care adjustment procedure focused on individual-level needs, which makes it an effective solution for relatively rare and high-risk conditions. A woman with a high-risk pregnancy due to coexisting complex conditions, such as diabetes and HIV, is one hypothetical scenario in which this approach will be effective (Soares & Higarashi, 2019). Regarding benefits, individualized needs assessments based on medical specialists’ concerted efforts can support the prevention of health crises and admissions to neonatal and adult ICU units. The presence of co-occurring multisystemic conditions maximizes the patient’s need for carefully adjusted pharmaceutical and non-pharmaceutical treatments to prevent complications and HIV transmission to the child. Therefore, focused attention to the patient’s case can be a life-saving approach. Finally, case management is beneficial since social workers’ engagement can facilitate the assessment and resolution of the client’s lifestyle-related contributors to contracting the virus and insufficient quality of diabetic self-care.
Despite being advertised as a patient-centered approach to service provision, case management is not always implemented successfully. From my practice, one example of failure was when a medical case manager working for an inpatient facility did not provide patient education in its entirety. The patient survived a closed brain injury and received the necessary surgical services and neuropsychological assessments to stabilize her condition and ensure the absence of life-threatening complications. After stitch removal and documenting the signs of wound healing, the hospital discharged the patient and provided some misleading information on when to visit the local care provider. The lack of coordination resulted in missing the early signs of stitch infection.
To manage these circumstances and prevent unwanted outcomes, I would ensure the quality of education and information exchange. Before proceeding with the discharge procedure, assessing the client’s health literacy in terms of caring for wounds closed with stitches would be essential (Netemeyer et al., 2020). It would confirm her capacity to recognize the warning signs requiring an urgent medical visit. Also, I would provide the patient with clearly documented self-assessment recommendations in written form, including unambiguous instructions regarding the promotion of wound healing and practices to avoid. Finally, another essential measure to improve care quality in terms of inter-provider coordination would involve contacting the patient’s physician directly and sharing the necessary details and contact information to prevent a delayed appointment.
References
Dohmen, P. J., & Van Raaij, E. M. (2019). A new approach to preferred provider selection in health care. Health Policy, 123(3), 300-305. Web.
Netemeyer, R. G., Dobolyi, D. G., Abbasi, A., Clifford, G., & Taylor, H. (2020). Health literacy, health numeracy, and trust in doctor: Effects on key patient health outcomes. Journal of Consumer Affairs, 54(1), 3-42.
Soares, L. G., & Higarashi, I. H. (2019). Case management as a high-risk prenatal care strategy. Revista Brasileira de Enfermagem, 72, 692-699.