Case or Care Management

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To know what has to be done, then do it, comprises the whole philosophy of practical life.

Sir William Osler

Guidelines are an expected part of medical practice in today’s society. However, guidelines cannot be blindly accepted or considered inviolate. If that were to be the case, they would cease to be guidelines and would become “standards” or even “mandates”. Guidelines and their application must be directed primarily toward the well-being of the patient. The term “cost-effectiveness” should refer to efficiency with regard to time, safety, and utilization of resources for patient care, and should NOT be used as a means to maximize profit or for any other purpose that does not have the patient as the primary concern.

Statement on the use of proprietary guidelines by managed care organizations.

American College of Surgeons Bull Am Coll Surg 33-4, March 1998

Guidelines can in no way encompass every diagnosis or treatment of all disease states, nor can they include the variations that occur in the complexity of the human response to disease processes, which includes co-morbid conditions. Where clear discrepancies of opinion exist, the licensed physician as the caretaker of the patient must be responsible for guiding the individual patient’s course leading to diagnosis and treatment.

Statement on the use of proprietary guidelines by managed care organizations.

American College of Surgeons Bull Am Coll Surg 33-4, March 1998

Guidelines should be formulated such that they cannot automatically be used as a basis for disciplinary action or litigation if the physician or surgeon determines that strict adherence to their provisions is not in the patient’s best interest. The guidelines should be flexible to permit variations for patient condition and circumstances and should provide options for these variations, including severity of illness and co-morbid conditions. The guidelines should be formulated to consider the totality of an episode of care. For example, discharge criteria must take into account the supportive resources that are available to the patient, such as convalescent care, home care, hospice care, family availability, and so on.

Statement on the use of proprietary guidelines by managed care organizations.

American College of Surgeons Bull Am Coll Surg 33-4, March 1998

Note: Referral to the preceding reference in its entirety is recommended reading.

	Preface, Disclaimers, Other important information
	Introduction to case or care management
	Geriatric Case Managers
	Patient Selection for CM
	Case Management Program
	CM - What is it?
	CM skills
	CM Information Systems
	Mentoring
	CM - policy and procedures
	Social Work Case Management Competency Requirements
	Certification requirements for social work case manager
	Case Management Accreditation
	Hospital UM/Care or Case Management Staff Functions
	Roles and responsibilities of hospital-care focused UM staff
	Roles and responsibilities of ambulatory-care focused UM staff
	Primary case manager
	Specialty CM/Clinical Nurse Specialist - roles and responsibilities
	Criteria for specialty case management referrals and case acceptance
	Specialty case management - policy and procedures
	Telephone case management
	Criteria for Social Service/Counseling Management -
	Specialty case manager - Case closing
	Intake Form - example content
	Specialty case manager - Discharge form
	Hospital case manager - UM variance reports
	CM: Skilled Nursing Facility
	Skilled vs Custodial (non-skilled) Levels of Care Services
	Custodial Level of Care – Questions and Answers (handout)
	What are the concerns about SNF admissions?
	CM: Home health and hospice services
	Post-discharge Case Management
	Patient Choice re: HHA Ownership Disclosure Form – Example
	Inappropriate Admissions - Change in Status
	CM: Discharge planning P&P
	Hospitalist program post-discharge transitional management of care
	CM: Homebound program
	Homebound program assessment survey
	High risk screens for new health plan members
	CM: New patient preliminary screening triggers and actions
	CM: Outcome Measures
	CM: Addiction Management
	Case Management in the ED for High Utilizers
	High risk case detection for focused case management
	CM Screen example for high risk patients
	Case management for disease specific referral programs
	Cases (example list) to screen or target for CM services
	Congestive heart failure CM
	Diabetic Case Management
	Nutritional case management
	Heparin-coumadin conversion program
	HIV – Case Management
	Hip Fracture – Case Management
	Obstetrical case management
	End-of-life care - case management
	Palliative care
	Mental Health Case Management Services - protocols, policy Ø CM triggers for the patient requiring behavioral health care Ø CM: Behavioral Healthcare – Policy example Ø Clinical case management Ø Community-based services Ø Depression Care - Case Management Ø Children/Adolescent Case Management Services - Oklahoma Foundation for Medical Quality (OFMQ) Case Management Program Ø Client Assessment Record (CAR)
	Case Loads – 2001 survey data
	*Position descriptions*
	Hospital Director, Case Management Services
	Case Manager, Primary Care/Ambulatory Care
	Case Manager, Hospital
	Case Manager, Specialty Care
	HIV/AIDs Nurse Case Manager
	Case Management Coordinator
	Social Worker, MSW
	Social Worker Case Manager Competency Requirement List
	Social Work Director
	Discharge Planner: Position description
	CM Candidate Screening Tool
	CM: Duties
	CM Credentialing Resources
	CM Plan - example
	Care coordination program - example
	CM-related organizations
	CM references and resources
	Case-mix adjustment; severity of illness resource
	Physician advisor role;
	Web Sites – Case Management, Nursing
	CM Notes