Nursing case management and critical pathways of care

NURSING CASE MANAGEMENT AND CRITICAL PATHWAYS OF CARE

PRESENTED BY

MS JIYA G PANTHANALIL

IST YEAR MSC NURSING

NIMHANS, BANGALORE

INTRODUCTION

Concept of case management evolved with advent of diagnosis related groups (DRGs) and shorter hospital stays

Innovative model of care delivery that can result in improved client care

Clients are assigned a manager who negotiates with multiple providers to obtain diverse services

Decreases fragmentation of care

DEFINITION

•Managed care refers to a strategy employed by purchasers of health care services who make determinations about various types of services in order to maintain quality and control costs

Managed care exists in many settings:

•Insurance –based programs•Employer –based medical providerships•Social service programs•The public health sector

FEATURES OF CASE MANAGEMENT

•Method used to achieve managed care•Actual coordination of services with in the

fragmented health care system•Strives to help at-risk clients•Controls health care costs to consumer

and third party payers

COMPONENTS

Case finding

Assessment

Care planning

Care co-ordination

CASE FINDING

•Systematic method • identify individuals who are at risk of

hospital admissions•Aims at preventing unplanned admissions•Patients who are currently experiencing

multiple emergency admissions have fewer emergency admissions in future- ‘regression to the mean’

•Identify the patient before they deteriorate

ASSESSMENT

• Assessment of current level of ability

• Physical and social care needs

•Assessment is not restricted only to health needs

CARE PLANNINGCare plan address individuals’ full range

of needs including• Health, personal, social, economic,

educational, mental health, ethnic, and cultural background and circumstances

Care plan provides structure to individual’s care and ensure that goals of different services are aligned with each other

Care plan enables case manager to

•Make referrals to various services•Co-ordinate all the different services

he/she should liaise with•Ensure that referrals have been picked up

and acted on•Monitor whether individual has made any

progress

•Care plan should be viewed as a live document

•Review the individual’s health and social care needs and revise the care plan accordingly

•Care plan is in a constant state of change •It depends on individual’s condition and

how much progress has been made•It is an ongoing process that structures

and facilitates effective delivery of care over time

CARE CO-ORDINATION

Reduce duplications of health careAvoid gaps and reduce health and social care service costsImproved disease managementFaster discharge from hospital

COMMON ACTIVITIES IN CARE CO-ORDINATION

1. MEDICATION MANAGEMENT-Ensure that individual’s medication regimen is appropriate and upto date-adherence of treatment regimen and monitor for adverse effects-communicate with individual patient, general practice staff, specialists, pharmacists

2. SELF CARE SUPPORT

Providing general health education and advice

Providing health education and advice specific to individual’s long term conditions

Coaching about most appropriate service to contact related to health or when a crisis occurs

3. ADVOCACY AND NEGOTIATION

•Facilitates patient to have access to services and equipment identified in the care plan

•Case manager directly negotiate with service providers

•Speed up the process of obtaining medication, equipment or home care services

4. PSYCHO SOCIAL SUPPORT

•Good relationships fostered by regular contact make patients more confident and increase well being

•Psychological support is a key strategy in supporting self care

•Helps to identify and support individual to behavioural change and facilitate changes in future goals

5. MONITORING AND REVIEW

• A well written care plan is the basis for review• Frequency of monitoring depends on individual’s level of need• Monitoring can take placeDailyWeeklyMonthlyDirectly in individual’s homeThrough remote monitoring(by telephone, telehealth device)

TELE HEALTH SERVICE

6. CASE CLOSURE

Four possible methods of discharge from case management programme• Death• Self discharge• Decision by the case manager and multidisciplinary

team• patient’s risk of hospital admission identified by a

risk prediction tool falls below a certain level as determined by case management programme

FACTORS DETERMINING EFFECTIVE CASE MANAGEMENT

The key enabling factors includeRole and skills of case manager

• Assigned accountability• Role and remit• Skills and support• Building relationships

Programme design• Targeting and eligibility

• Manageable case load

• Single point of care

• Effective use of data and communication processes

Factors within the wider system

• Shared vision and objectives• Close links between health and social care• Aligned financial flows and incentives• Stakeholder engagement• Provision of services in the community

ROLES AND SKILLS

• ASSIGNED ACCOUNTABILITYSuccessful case management requires an individual

or team with oversight of , and is accountable for the whole processes

Risk of fragmented care when accountability is not clearly assigned

•ROLE AND REMITClarity around the roles, responsibilities andboundaries of team members facilitate casemanagement

Confusion over roles can lead to tension

Perceived seniority of one service over another, and rivalry between different professionals can cause problem

•SKILLS AND SUPPORTKey skills that case managers need include:Inter personal skillsProblem solving skillsNegotiation and brokerage skillPrescribing qualificationsTraining

•BUILDING RELATIONSHIPSCase managers and their patients

Case managers and GPs

Case managers and hospital staff

PROGRAMME DESIGN

•TARGETING AND ELIGIBILITYCase finding helps in finding target cases(most at risk

and can benefit most)Where targeting is not accurate, programme will not

be cost effectiveProgramme should set out clear criteria for discharge

•MANAGEABLE CASE LOADMultiple roles include direct patient care, administrative tasks, attending or delivering training sessions and attending

meetingsIt can affect case managers’ capacity to provide care

for all patients

Number of patients manageable in a case load is influenced by:•Nature of patient’s conditions•Patients socio-demographic profiles•Patient’s circumstances•patient’s geographical area•patient’s individual characteristics•Time needed for non clinical activities

•SINGLE POINT OF ACCESS/SINGLE ASSESSMENT

Information sharing protocols can help to facilitate assessment process

Single Assessment Process (SAP) introduced in 2001aimed to reduce duplication in health and social careSAP was designed to standardise assessment across

different agencies and settings to raise overall standard of care and uniformity

• CONTINUITY OF CARECase manager should retain oversight over the

entirety of individual’s situation over time.

It gives a valuable sense of continuity for the patient

•EFFECTIVE USE OF DATA AND COMMUNICATION PROCESSES

Case management depends on exchange of information between partners working in different teams

All information is streamed centrally through case manager

Constant communication and timely information exchange with multidisciplinary team is vital

Critically patient has a single point of contact to whom they can address any queries or concerns

FACTORS WITHIN THE WIDER SYSTEM•SHARED VISION AND OBJECTIVESCase management need to develop clear goals and

objectivesIt should be understood by all partnersSense of shared responsibility and collaborative

approach facilitate better co-ordination of careWhere different partners or elements of system do

not share same vision, care co-ordination is difficult

•CLOSE LINKS BETWEEN HEALTH AND SOCIAL CARE

People with complex needs nearly always require support from both health and social care services

Social care is particularly important for patients in rehabilitation and re- ablement phases

•ALIGNED FINANCIAL FLOWS AND INCENTIVES

Different funding options have been used to support case management

Pooled budgets: eg. Castlefields example

Capitation: Fixed sum of money per patient can be used for a package of care services, where case management team takes responsibility for a patient’s care over time

STAKEHOLDER ENGAGEMENT

1. Case management needs trust, support and enthusiasm of local stakeholders

2. engage key professionals and teams in the case management

• PROVISION OF SERVICES WITH IN THE COMMUNITY•Case managers need to draw on a range

of resources and services in the community

•It helps patient to receive care at home•Community resources must be effectively

commissioned and case managers should know what is available and how to access it

ROLE OF NURSE AS CASE MANAGER

•Advocacy and education•Clinical care coordination/facilitation•Continuity/ transition management•Performance and outcomes management•Psychosocial management•Research and practice development•Utilisation review•Quality management•Discharge planner

CRITICAL PATHWAYS OF CARE

DEFINITION

•A care pathway is anticipated care placed in an appropriate time frame, written and agreed by a multi disciplinary team-Welsh National Leadership and Innovation Agency for Health care(2005)

•A critical pathway is a type of abbreviated plan of care that provides outcome-based guidelines for goal achievement within a designated length of stay.

CPC TEAM INCLUDES

•Nurse case manager•Clinical nurse specialist•Social worker•Psychiatrist•Psychologist•Dietician•Occupational therapist•Chaplain and others

HOW CPC IS CARRIED OUT

•The team decides what categories of care are to be performed, by what date and whom

•Each member of the team is then expected to carry out his or her functions according to the time line designated on the CPC

•The nurse as case manager is ultimately responsible for ensuring that each day of assignments is carried out

• If variations occur at any time in any of the categories of care, rationale must be documented in the progress notes

•The nurse contacts psychiatrists to inform him or her of the admission

•The psychiatrist performs additional assessments to determine if other consultations are required

•Within 24 hours, the interdisciplinary team meets to decide on other categories of care

•Completion of the CPC, and make individual care assignments from the CPC

•Each member of the team stays in contact with the nurse case manger regarding individual assignments.

• Ideally team meetings are held daily or every other day

•CPCs can be standardised because they are intended to be used with uncomplicated cases

•A CPC can be viewed as protocol for various clients with problems for which a designated outcome can be predicted

CHARACTERISTICS OF CPC

•Pathway is a projection of the client’s entire length of treatment

• Includes detailing of interdisciplinary intervention or processes and client outcomes each day from admission to discharge

•Pathway may be extended to include transfer to home care or another treatment facility

VARIANCES

DEFINITION

A variance is defined as an unexpected client response that “falls off” the pathway, requiring separate documentation and further investigation by the interdisciplinary team.

CAUSES OF PATHWAY VARIANCE

•Client or family•Caregivers•Hospital•Community•Payer(including insurance companies, health

maintenance organisations, or managed care organisations)

BENEFITS OF CPC

•Support the introduction of evidence based medicine and use of clinical guidelines

•Support clinical effectiveness, risk management and clinical audit

• Improve multidisciplinary communication, team work and care planning

•Can support continuity and co-ordination of care •Provide explicit and well defined standards of care

•Help to improve clinical outcomes•Ensure quality of care and provide a means of

continuous quality improvement•Help to improve communication between different

care sectors•Disseminate accepted standards of care•Provide baseline for future initiative•Reduce costs by shortening hospital stays

DEMERITS OF CPC

•Adaptability-on complicated case CPC becomes large and detailed, cumbersome and ineffective

•Crash action-changes from scheduled plan in a timeline, crash action involving reprioritizing each step

•Resource allocation-when resource don’t match CPC map, CPC begins to unravel

CONCLUSION

Critical pathways are tools to achieve patient or programme outcomes.

It is the process of team collaboration that ultimately produce quality outcome

Case management is critical to the success of pathways

By guiding pathway implementation and variance analysis, case manger can assure value to patient through out the continuum

THANKYOU........