The definition of a Case manager was revised in 2009 by the Case Management Society of America. That definition continues to be a "collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options that meet an individual's and family's comprehensive health needs. This is accomplished through communication, available resources to promote quality, cost effective outcomes." The philosophy of case management involves the basic tenet that all benefit when a patient achieves wellness, optimal functional capacity." The benefits extend to the patient, the patient's support system the healthcare system and the reimbursement system (Medicare, private insurance).
Case Management normally operates in a business community, thus Case Managers at Premier RN Geriatric Care ®LLC, understand the business scope of their practice. Case Mangers are experienced RN's and MSW, Social workers that establish relationships with Continuing Care Retirement Communities, Community services such as business vendors that supply goods and services to clients.
Focused and frequent communications between Case Managers and physicians must be established, and maintained. Case managers at Premier RN Geriatric Care ®LLC have developed a model to assess a client, develop a plan of care and set up appointments as needed with Primary care Physicians, and Speiciality Physicians to Maintain wellness. The RN nrmally accompanies the client to the MD office and is able to communicate the needs of the client, receive new orders, medication changes and establish the changes for the client in the continuing care paln, The Case management role does not end here, and the Case manager needs to define their role to the Physician. The Case Manager role in the community is often not understood or is not a familiar role to the Physician. Case Managers can carry the care plan of the client into the social, environmental, educational and support services /aspects of care. Case Managers can integrate community services, products by making necessary referrals and collaborating with the physicians, and coordinating care with resources in the community. The client/patient will benefit from the resouces that normally the Physician would not have referred them to.
Physician's see patient's in their offices and the follow up in the community may be lacking.
Continuing Education, of the Physician and his office team must be aware that the Self management Model of care is necessary to implement better patient outcomes. Self management that is a mutually agreed plan of care model between the client and the Case Manager and Physician. Planning patient self management is not telling a patient what to do. Effective self management involves interventions, goal setting and problem solving by the health care team. To proceed with the self management chronic care model for Diabetes, Stroke, Pain, CHF, the case manager and patient must collaborate. The case manager must assess the knowledge and behaviors, coordinate on a routine basis--at least weekly,advise the patient and team, including the MD using scientific evidence and current information, agree upon treatments and goals, allow the patient and families to identify problems and barriers and arrange necessary services for the patient.
The Medical Home Model is a health care/case management model to provide primary care, coordinate care, improve communications and relationships with MD's and involved family members. In March of 2007, the American College of Physicians, American Academy of Family Physicians, American Osteopathic Association,, American Academy of Pediatrics developed the principles for the Medical Home Model . Initially and as the Medical Home Model continues to develop, the RN Case Manager is an integral and key professional to focus on the Medical Home Model Team and Principles..
The characteristics of the principles are a Primary Care Physician Medical Practice, taking into account the whole oerson when the patient is being diagnosed and treated, coordination of care, focus on patient centered outcomes of quality, safety of the medical care , increased patient access and cost savings.
Case Managers also are called upon when the case involving a serious, complex and costly service agreement with poor outcomes. A red flag is an indication that the case involving the patient is not routine and will generally benefit from Case Management Services. For instance Catastrophic illneses are red flags for many group insurance plans, Workman's comp claims that involve many hours of lost time at work, and devastatin long term illnesses.
Also, Multiple and frequent hospitaizations and Emergency Room visits and having multiple physicians are red flag indicators.
Case mangers are effective at working through insurance claims departments to work with serious cases. The goal of the case manager becomes one of interpreting, collecting documentation to stream line medical care by creating a revised care plan and services. Ultimately the case manger will work thru cost containment measures with the insurance companies.
RN Case Management in The Community
RN Case Managers are very knowledeable in the clinical setting , collaborating with the medical team, coordinating care to accomplish cost effective and a better quality of living outcomes for patients, clients in the commnunity. Case Management Services should be available across the community. We emphasize the Primary care Physician/Medical Home Model, however RN Case Managers can be integral in Law Practices, As Health Coaches to Corporations, Consultants to Insurance Companies
RN Case managers focus on wellness, quality of life, coordination of care, as Integral profesionals in the community. RN Case Managers are able to customize and form a unique team with patients, clients to help identify problems, set manageable goals and provide reinforcement for positive outcomes.