Introduction
The health care environment has been undergoing major transformations in the recent past. This has created the need for nurses to enhance their creativity while delivering care. New systems that guarantee quality and cost-effective care are necessary especially in these times of diminishing human and physical resources, as well as constrained reimbursement. Nursing case management has proved to be among the ways through which health care delivery can offer high quality, effective resource utilization, and patient-centered care. A case management nurse plays an integral role in the healthcare team. He or she monitors all aspects of care that the patient is receiving ensuring that each step achieves the targeted result (Fitzpatrick & Ea, 2012).
This class of nurses is in constant communication with other stakeholders such as physicians and health-related services providers. This will guarantee patient access to the most effective services. As such, once a treatment has been ordered by the physician, it is the responsibility of the case manager to develop an elaborate plan of care and make a follow-up on its implementation. This includes ascertaining the quality of care, and a thorough utilization review to ensure the patient does receive high quality and adequate healthcare.
The role of the case manager entails both hospital and out-of-hospital patient requirements such as home care and/or rehabilitation (Brunner & Smeltzer, 2010). This paper will discuss and critically analyze how nurses have applied case management concepts to care for patients with high-risk complexions in various contexts. These contexts include complex physiological needs; complex functional health status; a family in crisis; a plan of care that is slow to advance; multiple hospitals and community transfers; complex discharge planning; complex pre and post-hospitalization course and unexpected readmission with 30 days of discharge.
Aspects of Application of Nursing Case Management
Successful nursing case management can only be achieved if it is targeted. Therefore, this calls for the case managers to be able to identify those clients at risk within the population. In the field of case management nursing, the case managers have used properly defined criteria in the screening process to determine the most appropriate management interventions. The aim of risk identification, as has been used by healthcare providers, is an integral and continuous process. In this process, health risks are prevented or managed to stop or delay any further deterioration arising from illness.
Early identification of patients with complex physiological needs is the initial step in addressing the health challenges through a comprehensive case management structure. Therefore, nurses use case management concepts in aligning the focus on managed care for the welfare of the population. As such, information on complex cases and how to handle them is obtained from case management referrals ranging from emergency rooms to hospitalization.
Through this information, the case managers have been able to classify members of the community with one or more chronic health conditions within various settings. This informs their next step of determining the intensity of risk to offer advice on the future medical care program protocol. Following evaluation of the risk level from the complex health condition, target interventions are put in place. This is then followed by an evaluation of the results of the targeted interventions (Olbort, et al, 2009).
A case in point is the program adopted by Kaiser Permanente Centre for Health Research. The center has an elaborate program for handling frail elderly patients through a well-targeted case management plan. A majority of Medicare members are classified by the facility in categories according to frailty. In one year, a self-report that describes the poor health of the patients is analyzed.
This data then guides the case manager in determining the appropriate medication management to recommend. The patients are assessed based on a frailty probability score, and a comprehensive in-home assessment may be done for the extreme cases. The provision of chronic care to patients with complex functional health statuses is a complex process. Therefore, the individual handling it must have adequate knowledge in resource mobilization (CMSA, 2010).
In most cases, nurses or social workers serving as case managers have had to be highly skilled in performing this role. Dealing with identified cases of chronic care involves among other roles conducting interviews with the at-risk patients including an in-home assessment for patients with extremely complex needs. The case manager then develops an appropriate structure to provide information and coordinate with relevant individuals involved in the case.
The nursing case manager has the skills to identify the present and future needs of the individual patients under his or her care. The case manager also determines the patients to be addressed by the community and those that fall under the physician’s jurisdiction. Based on the information the case manager has on the community resources, he or she makes the necessary connection through communication with the patients, clinical staff, and the family advising on the role they are meant to play in helping the patient recover (Koutoukidis, Lawrence & Tabbner, 2008).
Case management is also vital in helping a family in crisis. The family from which a patient requiring comprehensive care comes is also vital in the healing process of the patient. In patients suffering from addiction, the case manager has to advocate for the appropriate services to be availed to the family. This includes resources to help the family effectively engage in the rehabilitation process of their loved one. A case manager should help the family understand the context of the patient’s condition in simplified terms. Helping the family understand the role it is supposed to play in the patient’s recovery process may be a difficult undertaking.
However, this can be made easy by the nursing case manager availing convincing facts on the patient’s condition. This is because some medical cases may appear hopeless to a family in the lay context. The family may be called in to contribute more of their time and resources to the healing process of the patient, which may appear to be draining. Therefore, the case manager must learn to emphasize the need for the relentless offer of social support and encouragement.
This is as the patient continues to come to terms with their past behavior which may be a painful experience in case of addiction. The case manager offers support to the family and the patient while continually acting as a cheerleader. The case manager must take this as their role because other stakeholders such as the physician may not have the time or commitment to offer family support. This is necessitated by their participation in the patient’s healing process that majorly focuses on providing treatment only (Covey, 2007).
The case manager is required to play a role in improving a plan of care that is slow to advance. At all times, the case manager’s priority is the welfare of the patient. Therefore, the case manager must ensure that all required components of the organization address the patient’s problems. The case manager makes recommendations for the patient with high-risk complex needs. Most nurses serving in such situations have at times at loggerheads with the organizations as part of their role is patient welfare advocacy. Nurses have applied case management concepts to care for patients with high-risk complex needs inside the hospitals.
They have done this by advocating for patients’ right to access the appropriate care in the right setting, and at the appropriate time without unnecessary delays. By their skills, nurses serving as case managers understand professionally that the continued presence of the patient in hospital more than expected exposes them to nosocomial infections. With patients staying longer in the hospital, it means that their hospital bills or utilization of the hospital benefit schemes will increase. In other programs, such as the US Medicare program, hospitals would continue incurring expenses since the program pays a prospective amount that has no regard for length of stay or the cost of care to be provided while at the facility. Therefore, the case manager is an ideal candidate to advance change within the healthcare system (Fero, Herrick & Hu, 2011).
The case managers acquire disparate information due to their numerous roles and interactions with different stakeholders in the medical and social setting. The case manager can use the information to institute change by reviewing the competing demands of the patient, family, and the organization or health workers (Cohen & Cesta, 2005). The case manager is also involved in cases of multiple hospital and community transfers.
The transfer of the patient into the community or “hospital without walls” requires the case manager to consult with the physicians, family, and if necessary social workers. Patients with complex health needs may require varied services and environments. Such a patient may require assistance in undertaking their daily activities and in their preferred settings. Thus, the case manager organizes and coordinates the different stakeholders involved in the healing process to ensure the client achieves maximum recovery. If the patient has a history of severe mental or other deleterious health conditions, the case manager would have to coordinate the multiple transfers between the two areas based on the prevailing health conditions (Cox, 2010).
Complex discharge planning and complex pre and post-hospitalization course are other roles played by the nursing case manager. Effective and efficient planning in the discharge process must be adopted to regulate the length of stay in hospitals. The case manager plays a vital role in both discharge planning and post-hospital care provision. In discharging patients with complex needs, an assessment should be carried out to determine the appropriate transfer of the patient.
The case manager determines whether to refer the patient to a nursing home whether on a short or long-term basis or to send them directly home (Finn, 2011). The task calls for a consultation with all other stakeholders in the patient’s case such as the family and physicians. With this, the case leader offers both personal and professional opinions considering numerous factors surrounding the discharge including financial implications, health status consideration, and the health insurance component. The case manager has to be decisive and avail the necessary information, especially on post-acute care services owing to the weight of the discharged matter to all the stakeholders. This is guided by among other factors the availability of the services, cost, location, and quality of care (Nosbusch, 2010).
Upon the discharge of a patient with complex needs, unexpected readmission with 30 days of discharge may occur. The case manager plays a vital role in making post-discharge follow-ups of the patient. The case manager can develop an informed strategy concerning the model of the discharge plan by collecting data on rates of patient readmissions. If the patient is readmitted within thirty days due to the same medical condition he or she was discharged out for, then the case manager may institute a total overhaul of the complex discharge plan (Scott, 2010).
Conclusion
How nurses apply case management concepts to care for patients with high-risk complex needs inside and outside the hospital and over time seems to be influenced by many factors. The role of the case manager as depicted is complex. This is especially when handling patients with complex needs. The roles played entail coordination of activities in and out of the hospital environment. The case manager’s role is beneficial to both patients and nurses.
This is because it gives a clear guideline on how to handle the different situations and stakeholders as brought out in different contexts. These contexts include application of nursing case management for complex physiological needs; complex functional health status; a family in crisis; a plan of care that is slow to advance; multiple hospitals and community transfers; complex discharge planning; complex pre and post hospitalization course; unexpected readmission with 30 days of discharge.
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